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Benign Prostatic Hyperplasia
J. de la Rosette, G. Alivizatos, S. Madersbacher, C. Rioja Sanz, J. Nordling, M. Emberton, S. Gravas, M.C. Michel, M. Oelke,
© European Association of Urology 2006
TABLE OF CONTENTS
1. BACKGROUND 1.1 Prevalence 1.2 Is BPH a progressive disorder? 1.2.1 Indicators of progression 1.2.2 Conclusions 1.2.3 References RISK FACTORS 2.1 For developing the disease 2.2 For surgical treatment 2.3 References ASSESSMENT 3.1 Symptom scores 3.1.1 International Prostate Symptom Score (I-PPS) 3.1.2 Quality-of-life assessment 3.1.3 Symptom score as decision tool for treatment 3.1.4 Symptom score as outcome predictor 3.1.5 Conclusions 3.1.6 Recommendations 3.1.7 References 3.2 Prostate specific antigen (PSA) measurement 3.2.1 Factors influencing the serum levels of PSA 3.2.2 PSA and prediction of prostatic volume 3.2.3 PSA and probability of having prostate cancer 3.2.4 PSA and prediction of BPH-related outcomes 3.2.5 Conclusions 3.2.6 Recommendation 3.2.7 References 3.3 Creatinine measurement 3.3.1 Conclusions 3.3.2 References 3.4 Urinalysis 3.4.1 Recommendation 3.5 Digital rectal examination (DRE) 3.5.1 DRE and cancer detection 3.5.2 DRE and prostate size evaluation 3.5.3 Conclusions and recommendations 3.5.4 References 3.6 Imaging of the urinary tract 3.6.1 Upper urinary tract 3.6.2 Lower urinary tract 3.6.3 Urethra 3.6.4 Prostate 3.6.5 References 3.7 Voiding charts (diaries) 3.7.1 Conclusions 3.7.2 References 3.8 Uroflowmetry 3.8.1 References 3.9 Post-void residual volume (PVR) 3.10 Urodynamic studies 3.10.1 Outcome 3.10.2 Conclusions 3.10.3 References 3.11 Endoscopy 3.11.1 LUTS caused by bladder outlet obstruction 3.11.2 Morbidity of urethrocystoscopy
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3.11.3 Relationship between trabeculation and peak flow rate 3.11.4 Relationship between trabeculation and symptoms 3.11.5 Relationship between trabeculation and prostate size 3.11.6 Relationship between trabeculation and obstruction 3.11.7 Bladder diverticula and obstruction 3.11.8 Bladder stones and obstruction 3.11.9 Intravesical pathology 3.11.10 Conclusions 3.11.11 References Recommendations for assessment
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TREATMENT 4.1 Watchful waiting (WW) 4.1.1 Patient selection 4.1.2 Education, reassurance and periodic monitoring 4.1.3 Lifestyle advice 4.1.4 Conclusions 4.1.5 References 4.2 Medical treatment 4.2.1 5-Alpha reductase inhibitors 18.104.22.168 Finasteride (type 2, 5-Alpha reductase inhibitor) 22.214.171.124.1 Efficacy and clinical endpoints 126.96.36.199.2 Haematuria and finasteride 188.8.131.52.3 Side-effects 184.108.40.206.4 Effect on PSA 220.127.116.11 Dutasteride 18.104.22.168 Combination therapy 22.214.171.124 Conclusions 126.96.36.199 References 4.2.2 Alpha-blockers 188.8.131.52 Uroselectivity 184.108.40.206 Mechanism of action 220.127.116.11 Pharmacokinetics 18.104.22.168 Assessment 22.214.171.124 Clinical efficacy 126.96.36.199 Durability 188.8.131.52 Adverse effects 184.108.40.206 Acute urinary retention 220.127.116.11 Conclusions 18.104.22.168 References 4.2.3 Phytotherapeutic agents 22.214.171.124 Conclusions 126.96.36.199 References 4.3 Surgical management 4.3.1 Indications for surgery 4.3.2 Choice of surgical technique 4.3.3 Perioperative antibiotics 4.3.4 Treatment outcome 4.3.5 Complications 4.3.6 Long-term outcome 4.3.7 Conclusions and recommendations 4.3.8 References 4.4 Lasers 4.4.1 Laser types 4.4.2 Right-angle fibres 4.4.3 Interstitial Laser Coagulation (ILC) 4.4.4 Holmium laser resection of the prostate (HoLRP) 4.4.5 Conclusions 4.4.6 References 4.5 Transrectal high-intensity focused ultrasound (HIFU)
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4.5.1 Assessment 4.5.2 Procedure 4.5.3 Morbidity/complications 4.5.4 Outcome 4.5.5 Urodynamics 4.5.6 Quality of life and sexual function 4.5.7 Durability 4.5.8 Patient selection 4.5.9 Conclusions 4.5.10 References Transurethral needle ablation (TUNA®) 4.6.1 Assessment 4.6.2 Procedure 4.6.3 Morbidity/complications 4.6.4 Outcome 4.6.5 Randomized clinical trials 4.6.6 Impact on bladder outflow obstruction 4.6.7 Durability 4.6.8 Patient selection 4.6.9 Conclusions 4.6.10 References Transurethral microwave therapy (TUMT) 4.7.1 Assessment 4.7.2 Procedure 4.7.3 The microwave thermotherapy principle 4.7.4 Morbidity 4.7.5 High-intensity-dose-protocol 4.7.6 Prostatic temperature feedback treatment 4.7.7 Durability 4.7.8 Patient selection 4.7.9 Conclusions 4.7.10 References Recommendations for treatment
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FOLLOW-UP 5.1 Watchful waiting 5.2 Alpha-blocker therapy 5.3 5-Alpha-reductase inhibitors 5.4 Surgical management 5.5 Alternative therapies ABBREVIATIONS USED IN THE TEXT
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Benign prostatic hyperplasia (BPH) is a condition intimately related to ageing (1). Although it is not lifethreatening, its clinical manifestation as lower urinary tract symptoms (LUTS) reduces the patient’s quality of life (2). Troublesome LUTS can occur in up to 30% of men older than 65 years (3).
Although many epidemiological clinical studies have been conducted worldwide over the last 20 years, the prevalence of clinical BPH remains difficult to determine. A standardized clinical definition of BPH is lacking, which makes it intrinsically difficult to perform adequate epidemiological studies. Among the published epidemiological studies, some include probability samples from an entire country, while others represent agestratified random samples or enrol participants from general practice, hospital populations or responders to selective screening programmes. There is also a lack of homogeneity among these studies in the way in which BPH is assessed, with different questionnaires and methods of administration. Barry et al. have provided the histological prevalence of BPH, based on a review of five studies relating age to histological findings in human male prostate glands (4). Histological BPH was not found in men under the age of 30 years but its incidence rose with age, reaching a peak in the ninth decade. At that age, BPH was found in 88% of histological samples (4). A palpable enlargement of the prostate has been found in up to 20% of males in their 60s and in 43% in their 80s (5); however, prostate enlargement is not always related to clinical symptoms (2). Clinical BPH is a highly prevalent disease. By the age of 60 years, nearly 60% of the cohort of the Baltimore Longitudinal Study of Aging had some degree of clinical BPH (6). In the USA, results of the Olmstead County survey, in a sample of unselected Caucasian men aged 40-79 years, showed that moderate-to-severe symptoms can occur among 13% of men aged 40-49 years and among 28% of those older than 70 years (1). In Canada, 23% of the cohort studied presented with moderate-to-severe symptoms (7). The findings for prevalence of LUTS in Europe are similar to those in the USA. In Scotland and in the area of Maastricht, the Netherlands, the prevalence of symptoms increased from 14% of men in their 40s to 43% in their 60s (8,9). Depending on the sample, the prevalence of moderate-to-severe symptoms varies from 14% in France to 30% in the Netherlands (10,11). The proportion of men with moderate-to-severe symptoms doubles with each decade of life (10). Preliminary results of one of the most recent European epidemiological studies on the prevalence of LUTS show that approximately 30% of German males aged 50-80 years present with moderateto-severe symptoms according to the International Prostate Symptom Score (i.e. I-PSS > 7) (12). A multicentre study performed in different countries in Asia showed that the age-specific percentages of men with moderate-to-severe symptoms were higher than those in America (13,14). The prevalence increases from 18% for men in their 40s to 56% for those in their 70s (13). Curiously, the average weight of Japanese glands seemed to be smaller than those of their American counterparts (15). Despite methodological differences, some conclusions can be drawn from the studies mentioned above: • Mild urinary symptoms are very common among men aged 50 years and older. • Mild symptoms are associated with little bother, while moderate and severe symptoms are associated with increasingly higher levels of inconvenience and interference with living activities (16). • The same symptoms can cause different troublesome and daily living interference (17). • The correlation between symptoms, prostate size and urinary flow rate is relatively low (18). It must be stressed that there is still a need for an epidemiological definition of BPH and its true incidence has yet to be determined (19).
Is BPH a progressive disorder?
As it is almost impossible to obtain agreement on what it is that defines a man with LUTS/BPH, it seems logical to say that progression cannot be defined in terms of a transition from non-cases to cases. Instead, progression must be measured by documenting deterioration in any number of physiological variables that we associate with the LUTS/BPH syndrome. Traditionally these have included the following: • decrease in maximum flow rate • increase in residual volume • increase in prostate size • deterioration (increase) in symptom score. In addition, definable events, such as the occurrence of acute urinary retention or prostate surgery, have been used. Less commonly, changes in urodynamic variables and deterioration in disease-specific quality of life have been advocated. Considerable interest currently rests with PSA. It appears to be as good a predictor of progression as any of the variables mentioned above.
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3 10. These parameters could potentially be used in decisions about treatment management. BOO = bladder outlet obstruction. N/A = not available. have been associated with progression of BPH.7 3.9%d NR 10% over 4 years NR 10-39%e 2-year studies (30-34) North AmeNR NR rican (35) a Men with moderate to severe symptoms. Several other complications.1. The same strategy could be applied to patients who are at increased risk of progression based on recognised risk factors. N = no evidence. PSA level and prostate volume. DRE = digital rectal examination. BPE = benign prostatic enlargement. BII = BPH Impact Index. Patients who show signs of more pronounced disease progression could be targeted for preventative strategies. S = strong.2 mL/s in 4 yearsb NR 1. weak. 6 UPDATE MARCH 2004 . I-PSS = International Prostate Symptom Score. Other baseline risk factors can be identified. Qmax = maximum flow rate.based studies S S N N S N S N/A S S S Clinical trials N/W* N/N W/S* N S S/S* W/S* N/A S/S* W/S* N LUTS BPE BOO BPH Miscellaneous *Conditional risk factors: age and prostate-specific antigen (PSA).18 per year NR -1.9 NR NR 7% over 4 years 1. LUTS = lower urinary tract symptoms. QoL = quality of life. W = weak. PSA (PLESS) and prostate volume (combined 2-year placebo analysis). Although these are important. The actual rates of progression of the individual parameters as determined from the papers reviewed is shown in Table 2.3 11. such as symptom severity and decreased urinary flow rate.2%c 0.5-3. The strength of evidence for individual parameters as indicators of progression is summarised in Table 1 and is categorised as strong. Table 2: Rates of progression of individual parameters in BPH Study Rate of progression LUTS Flow rate (points) Prostate size Olmsted (23-27) Health Professional (28) PLESS (29) 0.3 in 4 yearsb NR -2% per year NR +0.0 34.1 Indicators of progression The strongest evidence to support progression comes from the Olmsted County (20) community-based study and the PLESS placebo group (21). but current data are not as convincing as those for age. Risk factors for progression were found to be age (Olmsted County).6-4. TRUS = transrectal ultrasonography. MRI = magnetic resonance imaging. The evidence for the progression of BPH has been summarised previously (22). Table 1: Strength of evidence for specific parameters as indicators of progression of benign prostatic hyperplasia (BPH) Parameter IPSS BII QoL DRE TRUS MRI Qmax Histology AUR Surgery Crossover/treatment Community.9% per year NR +14% in 4 years NR NR Acute urinary retentiona (Incidence/1000 person years) > 70 40-49 years years 3. or none. AUR = acute urinary retention.2. they are very rare and therefore could not be evaluated accurately in community-based and clinical studies.3 Surgerya (Incidence/1000 person years) > 70 40-49 years years 0. such as renal impairment and bladder dysfunction.
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in a cohort of 2. with a mean follow-up of 12 years. Imperato-McKinley J.com/ Boyle P. it can be concluded that the risk of needing surgery for BPH increases with age and with the degree of clinical symptoms at baseline. http://www. probably because of differences in sampling and methods of analysis. Men with one factor had a cumulative incidence of surgery of 9%. eds. it has been stated that diabetes and clinical BPH are associated more frequently than would be expected based on chance alone. those with two factors of 16%. Results of the different epidemiological studies are controversial. three in 10 men may undergo surgery for this condition (2). Multivariate analysis carried out on a sample of 16. such as hypertension or diabetes. http://www. nonsmokers. Epidemiology and natural history of benign prostatic hyperplasia. showed a positive association with surgery for age. Khoury S et al. In the Baltimore study. Paris.ncbi. Recently. REFERENCES Oishi K. but given the frequent occurrence of these conditions in ageing men a large proportion of patients can be expected to suffer from such an association (2.3). the main predictor for surgery was the presence of urinary symptoms. and a history of kidney X-ray and/or tuberculosis. the cumulative incidence for prostatectomy is 60% at 1 year and 80% at 7 years (11).3 for hesitancy in young men (aged < 65 years). Bracken BR. The effect of finasteride in men with benign prostatic hyperplasia. sensation of incomplete voiding and digital rectal enlargement of the prostate. Fourth International Consultation on BPH. From the above. Nevertheless. In the Veterans Normative Aging Study. Ultimately.nih. there is no strong evidence that smoking. the same study showed that increasing age was the predominant risk factor for surgery (8). low body mass index. The only true factors related to the development of the disease are age and hormonal status (4). Tenover JS et al. 1998. Br J Clin Pract 1994. they still represent the second most common major operation in aged men (7).9). July 1997. Walsh PC.35. In: Denis L. Barry JM et al. the odds ratio being 1. only nocturia (odds ratio 2. vasectomy. and those with three factors of 37%. The need for surgery increases with symptoms and is twice as high in men with a high baseline-symptom score than for those with a low score (10). Nocturia and changes in urinary stream seem to be the most important predictive symptoms. The risk of requiring subsequent surgery also varied with age.gov/entrez/query. Gormley GJ.nih.2 For surgical treatment Although the number of surgical procedures for BPH has declined in the USA and Europe over the last decade (6). For men presenting with urinary retention. produces a considerable bias (3). the likelihood of being treated surgically is about 3% (8. the three predictive symptoms for surgery were change in size and force of the urinary stream.gov/entrez/query.ncbi. Epidemiology of benign prostatic hyperplasia: risk factors and concomitance with hypertension. pp.1 RISK FACTORS For developing the disease The aetiology of BPH is multifactorial. Adriole GL. Plymouth: Health Publications.plymbridge.327:1185-1191. have been related to clinical BPH. for each of the five clinical urinary symptoms studied (12). the fact that both conditions increase with age and can cause partially similar voiding symptoms. obesity or high alcohol intake are risk factors in the development of clinical BPH.219 men. Bruskowitz RC. Stoner E. Currently. The Finasteride Study Group. Boyle P. 2.74(Suppl):18-22. 2.280 men.fcgi?cmd=Retrieve&db=PubMed&list_uids=1383816& dopt=Abstract 2. The crucial role of the testis has been recognized for more than a century and current research has extended into the field of molecular biology (5). http://www. Among older men. Chronic conditions. 25-59.3 1. New Engl J Med 1992 Oct 22.nlm.8 for nocturia and 4. Surgical risk depends on age and the presence of clinical symptoms. Griffiths K. In most cases only insufficient marginal differences can be established (1). McConnell JD.4) was predictive of surgery (13). urine pH greater than 5. 2. 10 UPDATE MARCH 2004 . Although more severe BPH symptoms (increased I-PSS and post-void residual) seem to be found in diabetic males even after age adjustment. Both of these risk factors are currently beyond prevention. aged at least 40 years. Geller J.fcgi?cmd=Retrieve&db=PubMed&list_uids=7519437& dopt=Abstract 2.nlm. In the absence of clinical symptoms.
Bay-Nielsen H et al.fcgi?cmd=Retrieve&db=PubMed&list_uids=1714659& dopt=Abstract 3. 8. Oxford: Isis Medical Media. 5. 13. 51-70. eds..gov/entrez/query. Etiology and disease process of benign prostatic hyperplasia.fcgi?cmd=Retrieve&db=PubMed&list_uids=4186545& dopt=Abstract Sidney S.ncbi. 38(Suppl 1):9-12. The natural history of prostatic obstruction: a prospective survey. reliability and responsiveness. Elinson J. Schalken JA. ASSESSMENT Diagnostic investigations have been classified as: • recommended: there is evidence to support the use of this test • optional: this test is done at the discretion of the clinician • not recommended: there is no evidence to support the use of this test.com/ Holtgrewe HL. Goldstein N.163:1725-1729. Vokonas PS. Lydick E.nlm.. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate.com/ Meigs JB. 6.. A number of instruments exist that can measure symptom severity.ncbi. de Labry L. Textbook of benign prostatic hyperplasia. Reda D. Quesenberry C Jr. Report from the Committee on the Economics of BPH.nih.(Suppl 2):33-50. http://www.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=1714653& dopt=Abstract Epstein RS. 4. Bressel HU. http://www. Coffey DS.1 Symptom scores Probably the best way to assess symptom severity is with a validated symptom score. N Engl J Med 1994. Bruskewitz RC. J Urol 2000. http://www. Urology 1991. Brown M. Metter EJ. 109-113. In: Kirby R et al.gov/entrez/query. Natural history of benign prostatic hyperplasia. Effect of diabetes on lower urinary tract symptoms in patients with benign prostatic hyperplasia. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=1714657& dopt=Abstract Diokno A. http://www.nih. Barry MJ. http://www.nih. pp. 125-135.fcgi?cmd=Retrieve&db=PubMed&list_uids=7527493& dopt=Abstract Craigen A. Textbook of Benign Prostatic Hyperplasia. 3.com/ Arrighi HM.148:1817-1821. Schumacher H. Herzog A. http://www.gov/entrez/query. 1996. Natural history of benign prostatic hyperplasia and risk of prostatectomy. Fozzard JL. J Urol 1992.gov/entrez/query.3.ncbi. Lydick EG. 12.ncbi.nih. eds. 9.fcgi?cmd=Retrieve&db=PubMed&list_uids=1279223& dopt=Abstract Wasson J. http://www. J R Coll Gen Pract 1969.gov/entrez/query.ncbi.ncbi. Jersey: Scientific Communication International.nih. Hickling J.gov/entrez/query.ncbi. eds. In: Kirby R et al.nlm.38(Suppl 1):13-19.nlm.nih. Risk factors for surgically treated benign prostatic hyperplasia in a prepaid health care plan.gov/entrez/query. pp. bother and quality of life (Table 3) (1).fcgi?cmd=Retrieve&db=PubMed&list_uids=2482772& dopt=Abstract Voller MC.fcgi?cmd=Retrieve&db=PubMed&list_uids=10799169& dopt=Abstract Isaacs JT. Age-related differences in risk factors for prostatectomy for benign prostatic hyperplasia: the VA Normative Aging Study. 11. in other words they measure what they UPDATE MARCH 2004 11 . Oxford: Isis Medical Media. Cattolica EV.nih. Keller AM.ncbi. http://www.nlm. Mehlburger L.nih. http://www. Sadler MC.isismedical. Saunders C. Guess HA. 10.nlm.334:75-79.isismedical.18:226-232.plymbridge.nlm. Urology 1991. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. 1996. Molecular genetics of benign prostatic hyperplasia. In: Cockett ATK et al. Goepel M. pp.nlm. Carpenter R. http://www. Most instruments in current use conform to acceptable standards of validity. Michel MC. Epidemiology of bladder emptying symptoms in elderly men. 7. the Baltimore Longitudinal Study of Aging. Third international consultation on benign prostatic hyperplasia (BPH). Prostate 1989. Ackermann R. Guess HA. Henderson WG.gov/entrez/query. 1996.35(Suppl):4-8. Urology 1991.
g. There is little evidence that physiological measures improve the chances of predicting a favourable symptomatic outcome. Patient with moderate symptoms might benefit from pharmacotherapy. the Medical Outcomes Study. moderate (8-19) and severe (20-35). One of the best known is the generic measure. 3.1 International Prostate Symptom Score (I-PSS) The I-PSS has become the international standard. a 36-item short-form health survey (SF36) (14). while patients with severe symptoms may derive most benefit from prostatectomy. 3. As men with mild symptoms have little room for improvement it is of little surprise that they do not experience high levels of symptom reduction following surgery. are stable over time and are able to reflect clinically important changes (2). Secondly. Although notions of appropriateness have not been well-studied. Three categories of symptom severity were described: mild (0-7). Increasing ‘bothersomeness’ was associated with a worsening of all dimensions of general health status and quality of life. prostate size or pressure-flow relationships (1. Increasing symptom severity was associated with worsening physical condition. The I-PSS appears less reliable in men over 65 years old (6) and careful linguistic validation needs to be undertaken prior to its use in non-North American cultures (7). 3. It has been used in a number of studies addressing men with lower urinary tract symptoms. The authors suggested that patients with mild symptoms were most appropriately managed by a watchful waiting approach. This lack of correlation has troubled many investigators and has led to some questions raised about the validity of the I-PSS. vitality. 8-10). 9-49% of those with moderate or severe urinary symptoms reported interference with some of their daily activities. has an 87% chance of experiencing a substantial symptom reduction (17). this question measures the extent to which patients tolerate their symptoms rather than evaluating their quality of life. there are numerous reports of symptom severity (as expressed by I-PSS) correlating poorly with peak urinary flow rate.1. It is derived from the American Urological Association (AUA) 7 score described by Barry and his colleagues in the early 1990s (3). 3. depending on the respondent’s activity. average flow rate. Correlation of the self-reported score to intermittency or to the strength of stream was poor (5). quality-of-life instruments have been used for clinical research. Using this score. Men report nocturia with accuracy but tend to overstate daytime frequency. By adding the scores (with equal weighting) to its constituent questions.purport to measure. there are statistical issues related to the clustering of values or data points. For example. a postal population survey among 217 men aged 55 years and over with LUTS showed that. I-PSS and physiological measures measure different things. A validated symptom score assesses symptom severity. The association between the outcome of this population survey and the degree of ‘bothersomeness’ was stronger than that with the I-PSS symptom score. 12 UPDATE MARCH 2004 . Correlations of similar magnitude have been seen in many other disease areas. social functioning. the proposed policy appears to hold true for patients with mild symptoms but is less reliable for men with moderate or severe symptoms (15). mental health and perception of general health.2 Quality-of-life assessment The impact of urinary symptoms on the quality of life is generally evaluated by means of question 8 of the I-PSS.3 Symptom score as decision tool for treatment Can symptom severity alone be used to allocate treatment? The US Agency for Health Care Policy and Research Guidelines (1) tried to do this. peak respiratory flow correlates poorly with patient’s own reports of the severity of their asthma. e.1. post-void residual volume. Firstly. It is a self-completed questionnaire used to measure general health status and quality of life. However. Age and cultural factors may be important. which will also result in poor correlation.1. The lack of correlation can be explained in two ways. and in both predicting and monitoring the response to therapy. 3. or more.5 Conclusions Evaluating symptom severity with a symptom score is an important part of the initial assessment of a man. Numerous authors have reported and commented upon the poor correlations between I-PSS and other physiological variables. It can be used to monitor change in symptoms over time or following an intervention.1. It is helpful in allocating treatment. The extent to which the selfreported scores reflect actual events has been questioned. A number of health-related. A man with a pre-operative I-PSS of 17.4 Symptom score as outcome predictor Symptom score may be one of the more powerful predictors of symptomatic outcome (16).1. a summary or index score is generated which has been shown to be an accurate reflection of a man’s overall symptoms over the preceding month (4).
PSA will ‘leak’ into the circulation. independent of total PSA levels (17). 3.2.14). This is why PSA is not considered as being cancer-specific. may influence serum PSA levels the level of PSA correlates with the volume of the prostate gland the higher the PSA level. log-linear relationship and that PSA has a good predictive value for assessing prostatic volume (7). age. Vesely et al. elevated free PSA levels could predict clinical BPH. Two other important factors.30 ng/mL per gram of tissue and 3. 3.3. family history. Both PSA forms were found to be able to predict the TRUS prostate volume (± 20%) in more than 90% of the cases (9). Roehrborn et al. I-PSS 3. trauma. Prediction of prostate volume can also be based on total and free PSA. were the first to correlate PSA serum values and volume of prostatic tissue (6).2. they found that the serum PSA contribution from BPH was 0. In a recent epidemiological study. must also be considered when evaluating PSA values in men with LUTS (2. small and clinically insignificant changes occur after DRE.2 Prostate-specific antigen (PSA) measurement Before selecting the proper treatment for men with LUTS. In addition. 3. These parameters were also related with long-term changes in symptom scores and flow rates.age. prostatitis and after urinary retention.2. These nomograms are being constructed from variables such as age.2 PSA and prediction of prostatic volume Stamey et al.1 Factors influencing the serum levels of PSA In cases where the architecture of the prostatic gland is disrupted. Other known causes of PSA serum elevations are biopsy of the prostate gland and ejaculation (1). BPH. race.1. 3.6 RECOMMENDATION The measurement of PSA is recommended when a diagnosis of prostatic carcinoma will change the decision made about which therapeutic option to use. since only minor variations in PSA reference ranges were found (5). age and race. 3. UPDATE MARCH 2004 13 . PSA. e. predictive nomograms have been developed by various groups.3).6 RECOMMENDATIONS Recommended investigations: • Clinical history • Symptom assessment • Physical examination • Validated symptom score.5 • • • • Conclusions various factors (cancer. PSA density and TRUS findings (13.5 ng/mL per cm3 of cancer tissue. every urologist will perform a DRE and most will measure the serum value of PSA.4 PSA and prediction of BPH-related outcomes In a series of studies.2. A recent community-based study of African-American men contradicts the beliefs of racial PSA differences. and therefore age-specific reference ranges must be adapted and interpreted according to race and ethnicity (4). At the same time. PSA and DRE .054 men. infection. African-Americans with no evidence of prostate carcinoma have higher PSA values after their fourth decade of life. DRE. but organ-specific. also found that prostate volume and serum PSA are significantly correlated and increase with advanced age (8). Potter et al. 3. For many years the value of 4ng/mL was considered as the upper normal limit of PSA (10) but lately a lower threshold of PSA for recommending prostate biopsy in younger men has shown to improve the clinical value of this test (11).and have calculated the likelihood of detecting prostate cancer on sextant TRUS-guided biopsies among 2. the greater is the probability of having prostate cancer the PSA level might predict the natural history of BPH.3 PSA and probability of having prostate cancer The chance of having prostate cancer is strongly related with the serum value of PSA. In their studies in the late 1980s. have shown that PSA and prostate volume have an agedependent. This occurs when prostatic carcinoma is present but also in BPH. (12) have used three clinical parameters . Roehrborn et al.16) have shown that PSA and prostatic volume can be used to evaluate the risks of either needing surgery or developing acute urinary retention. (15.2.g.2. In order to avoid unnecessary biopsies.
fcgi?cmd=Retrieve&db=PubMed&list_uids=10096388& dopt=Abstract Vesely S.153:184-189. http://www. Moparty B. Bansal BSG.50:239-243.org/ Laguna P. 2003.fcgi?cmd=Retrieve&db=PubMed&list_uids=9255295& dopt=Abstract Oesterling JE.nih. http://www. 8. 12. Wei JT. Strawderman MS.nlm. Cancer 2003.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=11164150& dopt=Abstract Stamey TA.fcgi?cmd=Retrieve&db=PubMed&list_uids=11394329& dopt=Abstract Cooney KA. Predictive modelling for the presence of prostate carcinoma using clinical. Montie JE.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10650506& dopt=Abstract Eastham JA.2. Waldstreicher J. Prostate specific antigen. de Torres IM.53:581-589.nlm. Curr Opin Urol 2000.ncbi. Sartor O. Wojno KJ. Damber JE. Ross LS. laboratory.gov/entrez/query. Knutson T.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377318& dopt=Abstract Kalra P. Partin A.nlm. Urology 1997.ncbi. JAMA 1993.gov/entrez/query.349:335-342. Hay AR. Serum prostate specific antigen as a predictor of prostate volume in men with benign prostatic hyperplasia. Racial variation in prostate specific antigen in a large cohort of men without prostate cancer. prostate volume.157:1100-1104. http://www.ama-assn.ncbi. 11.fcgi?cmd=Retrieve&db=PubMed&list_uids=10859448& dopt=Abstract Barry MJ. N Engl J Med. http://www.38:91-95.fcgi?cmd=Retrieve&db=PubMed&list_uids=12944191& dopt=Abstract Morote J. 4.gov/entrez/query. 13. 7. D’ Amico AV.fcgi?cmd=Retrieve&db=PubMed&list_uids=14508828& dopt=Abstract 2. Babaian RJ. Jacobsen SJ. Boyle P.nih. 3. Scand J Urol Nephrol.nih. 14 UPDATE MARCH 2004 .98:1417-1422. Doerr KM.nih.ncbi.nih. Age-specific distribution of serum prostate-specific antigen in a community-based study of African-American men.nlm. Catalona WJ.nlm. http://www. http://www.98:1849-1854.nlm. Lopez M. Prostate specific antigen as a serum marker for adenocarcinoma of the prostate.ncbi.ncbi.nih. Hsieh YC.gov/entrez/query. 6.nih. Freiha FS. http://www.gov/entrez/query.ncbi.gov/entrez/query. Chute CG.gov/entrez/query. Urology 200.nlm.gov/entrez/query. http://www. Richey W. Bartsch G.ncbi. Relationship between age.nlm. 14. Gould AL. Barrera E. and ultrasound parameters in patients with prostate specific antigen levels</= 10 ng/mL. A neurocomputational model for prostate carcinoma detection.344:1373-1377.ncbi. 2003. http://www.gov/entrez/query.nih. Catalona WJ. http://www. Testing for early diagnosis of prostate cancer. 10.7 1. Girman CJ.nih.57:91-96. Prediction of prostate volume based on total and free serum prostate specific antigen: is it reliable? Eur Urol 2000. prostate specific antigen and digital rectal examination as determinants of the probability of having prostate cancer.fcgi?cmd=Retrieve&db=PubMed&list_uids=2442609& dopt=Abstract Roehrborn CG.fcgi?cmd=Retrieve&db=PubMed&list_uids=14584066& dopt=Abstract Garzotto M. J La State Med Soc 2001. Klein T.nlm.nlm. Hudson RG.37:322-328. 5. 9. Togami J.ncbi. Redwine E.nih. symptom score and uroflowmetry in men with lower urinary tract symptoms. Dahlstrand C. Mori M. N Engl J Med 1987. http://jama. Alivizatos G. Beer TM.nih. Brawer MK. Kuntz KM.nlm.317:909-916.fcgi?cmd=Retrieve&db=PubMed&list_uids=11333995& dopt=Abstract Punglia RS. Roehl KA. prostate-specific antigen. Urology 1999. Schottenfeld D.fcgi?cmd=Retrieve&db=PubMed&list_uids=12878740& dopt=Abstract Potter SR. Cancer 2003. Peters L. N Engl J Med 2001. http://www.nlm. Effect of verification bias on screening for prostate cancer by measurement of prostate-specific antigen. Partin AW. Encabo G. Heeringa SG. Panser LA. Taylor A.nlm. http://www.270:860-866. Prostate specific antigen and benign prostatic hyperplasia. Niederberger CS.ncbi.10:3-8. http://www. Horniger W. Urology 2001. Guess HA. Alcser KH.3. Taylor JM.ncbi. Lieber MM.nih. Tinzl M. Smith DS. Age.gov/entrez/query. Dicuio M. Yang N.gov/entrez/query. Sullivan J. Effect of ejaculation on serum total and free prostate specific antigen concentrations. REFERENCES Herschman JD.gov/entrez/query. Serum prostate specific antigen in a community-based population of healthy men: establishment of age-specific reference ranges.nih. McNeal JE.
http://www. 17. Most studies have found that the incidence of azotaemia in men with BPH varies from 15-30% (5.58:210-216.gov/entrez/query. Malice MP. as measured by an improvement in quality of life. Cockett AT. Br Med J 1989.6). http://www. as the use of certain α-blockers might cause additional problems in men with renal insufficiency. 16.15. proper therapy can be offered to the right men and the costs of long-term renal damage and post-surgical complications can be avoided. In this way. it was shown that patients with BPH and renal insufficiency had a 25% risk of developing post-operative complications compared with the 17% risk in patients with normal renal function (2). REFERENCES Sacks SH. UPDATE MARCH 2004 15 . This study also noted that it was rather rare to find patients with high creatinine levels due to bladder outlet obstruction only. it is probably cost effective to measure serum creatinine levels in all patients.3. A comparative study of 13 participating institutions evaluating 3. Bevan A.ncbi. Urology 2001. This point is increasingly emphasized.nlm.gov/entrez/query.nih. (10) studied the additional value of renal ultrasonography in the assessment of patients with BPH and concluded that only those with an elevated creatinine level needed such an investigation.nih.gov/entrez/query.nih. Collins MM. Clinical predictors of spontaneous acute urinary retention in men with LUTS and clinical BPH: A comprehensive analysis of the pooled placebo groups of several large clinical trials.ncbi.ncbi.298:156-159. McConnell JD. (8) reported a study in which voiding dysfunction of a non-neurogenic aetiology did not appear to be a risk factor for elevated BUN (blood urea/nitrogen) and creatinine levels. It was also shown that neither the symptom score nor the quality-of-life assessment was associated with serum creatinine levels in patients with BPH. Narayan P. 3.fcgi?cmd=Retrieve&db=PubMed&list_uids=11908420& dopt=Abstract 2. Holtgrewe HL.nlm. Comiter et al. Despite all of the above.885 patients.1 CONCLUSIONS As it is difficult to select those with renal insufficiency from among evaluable BPH patients.gov/entrez/query.nlm. Quezada WA.e. it is probably unwise to avoid measuring serum creatinine levels in patients undergoing BPH evaluation in an effort to minimize costs.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=12121721&dopt=Abstract Roehrborn CG. Saltzman B. Proscar Long-term Efficacy and Safety Study. Earlier studies also showed a much higher mortality among BPH patients who underwent surgical treatment when renal insufficiency was present at the same time (3. Will EJ. these figures might be overestimates as these studies involved patients undergoing surgical treatment (i.nlm.2 1. Cook TJ.gov/entrez/query. Late renal failure due to prostatic outflow obstruction: a preventable disease.3. Waldstreicher J. Transurethral prostatectomy: immediate and postoperative complications. Although the recently released MTOP’s data suggest that creatinine measurements might not be indicated. Aparicio SA.42:1-6. Johnson-Levonas AO. http://www.ncbi. PLESS Study Group. This study suggests that it is not necessary to control the serum creatinine if voiding is normal. In the report from the AHCPR (11) and in the recommendations of the Fourth International Consultation on BPH (12). Eur Urol 2002.fcgi?cmd=Retrieve&db=PubMed&list_uids=11489703& dopt=Abstract Meigs JB. However. J Urol 1989. we feel that this study does not address this issue.ncbi. Barry MJ. Koch et al. Ten years ago. Bergner D. diabetes and hypertension were the most probable causes of the elevated creatinine level among this group of patients. 3.141:243-247. Roehrborn CG. Davison AM. Bruskewitz et al. (9) also found that an isolated serum creatinine level could not predict the outcome after TURP.4). Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men. A recent study evaluated 246 men presenting with BPH symptoms and found that approximately one in 10 (11%) had renal insufficiency (7). http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11520654& dopt=Abstract 3.nih. those with severe symptoms and with urinary retention).nih. Oliver DO.fcgi?cmd=Retrieve&db=PubMed&list_uids=2466506& dopt=Abstract Mebust WK. http://www. Girman CJ. Cook TJ.54:935-944. When renal dysfunction was present. Gray T. McKinlay JB.3 Creatinine measurement It is well-accepted today that bladder outlet obstruction due to BPH might cause hydronephrosis and renal failure (1). J Clin Epidemiol 2001. Mohr B. Storage (irritative) and voiding (obstructive) symptoms as predictors of benign prostatic hyperplasia progression and related outcomes. the measurement of creatinine is highly recommended. Peters PC.
Occult progressive renal damage in the elderly male due to benign prostatic hypertrophy. Reda DJ. 5. Initial diagnostic evaluation of men with lower urinary tract symptoms. Karrison TG.nih. causing unnecessary further diagnostic measures in a large number of patients.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490828& dopt=Abstract McConnell JD. Factors influencing the mortality and morbidity of transurethral prostatectomy: a study of 2015 cases.1 RECOMMENDATION Urinalysis is recommended in the primary evaluation. Firstly. Geneva. Sullivan MP. Schacterle RS.nih.nih.4 Urinalysis Since LUTS is not only observed in patients with BPH. eds.ahrq. Testing to predict outcome after transurethral resection of the prostate. Correa R et al. microscopic urine analysis has not been accepted as a screening test for the early detection of severe urological diseases. Quick Reference Guide for Clinicians. http://www. Ezz El Din K.nih. Urodynamic risk factors for renal dysfunction in men with obstructive and non-obstructive voiding dysfunction. Barry MJ. However. Channel Islands. http://www. Bales GT. In: Denis L. 167-254.nlm.ncbi.3.nih. it enhances the capacity to estimate prostate volume. J Am Geriatr Soc 1979.gov/entrez/query. it can help to determine the co-existence of prostatic carcinoma. However.fcgi?cmd=Retrieve&db=PubMed&list_uids=9145973& dopt=Abstract Comiter GV. de Wildt MJ.nih.nlm. In: Cockett AT et al. Boner G. de la Rosette JJ.nlm. AHCPR publication 94-0583. 11. J Urol 1962. http://www.ncbi. Overall. 8. http://www. but also frequently in men with urinary tract infections.gov/entrez/query.. Artibani W. Khoury S et al.112:643-646. This is mainly due to the low specificity of this highly sensitive test. 9.fcgi?cmd=Retrieve&db=PubMed&list_uids=4424347& dopt=Abstract Roehrborn CG. Proceedings of the Fourth International Consultation on BPH. Mukamel E. 3. Proceedings of the Third International Consultation on Benign Prostatic Hyperplasia (BPH). Agency for Health Care Policy and Research. Valk WL. 4. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=89133& dopt=Abstract Gerber GS. Phelan M. Debruyne FM. Valk WL. 6. we concluded that this inexpensive test which does not require sophisticated technical equipment should be incorporated in the primary evaluation of any patient presenting with LUTS. US Department of Health and Human Services: Rockville. MD. 12. Cohen LH. Holtgrewe HL.nlm.4. Goldfisher ER. http://www. 10. and in at least 25% of patients with carcinoma of the bladder.27:403-406. 155:186-189.nlm. Paris.fcgi?cmd=Retrieve&db=PubMed&list_uids=13908592& dopt=Abstract Melchior J. February 1994. Secondly. it should be noted that there is little evidence in the literature to support this conclusion.. Serum creatinine measurement in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia.ncbi. J Urol 1997.gov/clinic/medtep/bphguide.gov/entrez/query. analytical and microscopic urine analysis was considered to be mandatory. such as malignancies.gov/entrez/query. as prostate size has been shown 16 UPDATE MARCH 2004 . Urology 1997. Bruskewitz RC. The outcome of renal ultrasound in the assessment of 556 consecutive patients with benign prostatic hyperplasia. J Urol 1974. and in this way may assist in choosing the right treatment.gov/entrez/query.158:181-185.fcgi?cmd=Retrieve&db=PubMed&list_uids=9120927& dopt=Abstract Koch WF.com/ 3. J Urol 1995. Mebust WK. 1998. Wasson JH.nlm. whether related or not to benign enlargement of the gland. J Urol 1997. Public Health Service.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186351& dopt=Abstract Bruskewitz RC.ncbi.nih. July 1997. http://www. Nissenkorn I.49:697-702. 3. Griffiths K. pp.gov/entrez/query. Plymouth: Health Publications.ncbi. 179-265. Scientific Communication International Jersey. Foret JD.ncbi. Servadio C. 1996.157:1304-1308. 7. eds. Transurethral prostatectomy in the azotemic patient. http://www.5 Digital rectal examination (DRE) Digital rectal examination (DRE) is an important examination in men with LUTS for two reasons.87:450-459.htm#bphimp Koyanagi T. pp.gov/entrez/query. Benign Prostatic Hyperplasia: Diagnosis and Treatment. http://www.plymbridge. Valla SV.nlm.ncbi. Barrett L.
Age. http://www. Dupont A. PSA and DRE. Screening decreases prostate cancer death: first analysis of the 1988 Quebec prospective randomized controlled trial. an estimation of the prostate gland volume will help the urologist to select the most suitable form of treatment with the lowest cost and best outcome. pain. They concluded that both methods were equal in completeness of examination. used three clinical parameters.nih. Diamond P.gov/entrez/query.21) (7). Lung.57:1100-1104. Although different methods and criteria were used in the four studies. DRE has been used as an ancillary screening tool. age. Urology 2001.com/ Potter SR. DRE has been used in the screening process. is recommended. Colorectal and Ovarian (PLCO) screening trial and in the European Randomized study of Screening for Prostate Cancer in Europe (ERSPC). In: Chatelain C. 3. These figures are based on screening studies and it is believed that DRE will have a higher PPV for cancer among men with LUTS.051 men. Cidre J. Similar models to assist training for DRE examinations have been proposed by other groups as well (11). to determine the probability of having prostate cancer and constructed a nomogram to help in the decision whether or not to perform a prostate biopsy. McConnell J eds. In this study. pp. Recommendation: DRE is recommended in the evaluation of men with LUTS. such as surgery. was abandoned (6). Frank et al. Bosch J. 169-188. Tinzl M. DRE is useful in evaluating the size of the prostate gland and also in order to exclude other pelvic pathologies. Prostate 1999. Bartsch G. Levesque J.2 DRE and prostate size evaluation A number of options are currently available for the treatment of patients with BPH. have compared the knee-elbow to the left-lateral position of the patient in examining and evaluating the prostate.5. Fifth International Consultation on BPH. prostate-specific antigen. finasteride.5.3 1. Partin AW.4. Foo S. Horniger W.plymbridge. Plymbridge Distributions. UPDATE MARCH 2004 17 . Denis L.gov/entrez/query. REFERENCES Resnick M. 1. 3. http://www. Correct estimation of the prostatic volume by DRE is not an easy task and therefore investigators for the PLCO (Prostate.ncbi. CONCLUSIONS AND RECOMMENDATION DRE has been used in all major screening trials but its actual impact in the early diagnosis of PCa has been questioned. http://www. Frand I. Response to certain types of therapy.. particularly if the volume was greater than 30 mL. but proper training is needed. In patients for whom invasive therapy. Finally. 2.38:83-91. and digital rectal examination as determinants of the probability of having prostate cancer. depends on the actual prostate volume. as these patients are usually older. Khoury S.to be a determining factor for certain treatment options. DRE results were not a significant predictor of prostate cancer (P=0. Colorectal and Ovarian Cancer) trial have described quality-control procedures for DRE examination (8).ncbi. Potter et al. and embarrassment (12).fcgi?cmd=Retrieve&db=PubMed&list_uids=9973093& dopt=Abstract 2. Cusan L. Roehrborn has analyzed the data from four studies in which estimations of prostate volume by DRE were compared with those performed by TRUS (9). Roehrborn developed a model of visual aids to help urologists predict prostate volume more accurately (10).5. Gomez JL. the “Innsbruck”(4) and the “Olmsted County”(5) screening trials.5. Belanger A. In the “Quebec” (3). Candas B.1 DRE and cancer detection The positive predictive value (PPV) of a suspicious DRE to actually diagnose prostate cancer is 26-34% (1). e. In the European Prostate Cancer Detection Study (EPCDS) of 1.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377318& dopt=Abstract Labrie F. In 1997 the use of DRE in the ERSPC trial as a screening test. Foo K. 3. In the Prostate. it was concluded that underestimation of DRE increased with increasing TRUS volume. Suburu RE. 2000.nih.nlm. 3. Ackerman R. 3.nlm. DRE had a significant influence on the likelihood of a positive biopsy in all PSA and age ranges (2). Lung. It is well-accepted that TRUS is more accurate in determining prostate volume than DRE. Benign prostatic hyperplasia.g. For this reason.
Schonitzer D. Urol Clin N Am 2003.nlm. IEEE Trans Biomed Eng 1999. Urology 2001. Severi G. Similar findings. Robertson C. Ghawidel K. http://www.nlm. Quality control of cancer screening examination procedures in the Prostate.1 Upper urinary tract A recent survey of 24 urological centres in the UK found that 21 of 24 centres (79%) used either intravenous urography (IVU) or sonography.161:529-533. http://www. Rhodes T.ncbi.163:1144-1148.ncbi. 6. Colorectal and Ovarian Cancer Screening Trial Project Team. BJU Int 2001.nih. Oliver S. Minnesota. Bartsch G. an imaging modality for patients with LUTS should provide both imaging of the urinary tract and demonstrate the morphological effects of prostate pathology upon the rest of the lower and/or upper urinary tract. Montoya J. J Urol 1999.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377314& dopt=Abstract Burdea G. Oberaigner W.13). Lieber MM. Urology 1998. Accurate determination of prostate size via digital rectal examination and transrectal ultrasound.gov/entrez/query. Thomas K. Reissigl A.gov/entrez/query. Basharkhah A. Urology 2001.gov/entrez/query. http://www. Jacobsen SJ.nih. O’Brien B.nlm. Ideally. Tyrol Prostate Cancer Screening Group. Couch or crouch? Examining the prostate. Lung. Patounakis G.gov/entrez/query. In parallel with endoscopy.gov/entrez/query.51(Suppl 4A):19-22. have been reported in the USA (15).nih. Boyle P.nih. Virtual reality-based training for the diagnosis of prostate cancer. http://www.ncbi.6. Remzi M. Interexaminer reliability and validity of a three-dimensional model to assess prostate volume by digital rectal examination. 5.051 men.nih.30:239-251.nlm. Katusic SK. Lung.nlm.nih.4. Marberger M.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=11549491& dopt=Abstract Roberts RO.nih. Sech S. 11. particularly prior to prostate surgery. Control Clin Trials 2000. Prostate cancer mortality after introduction of prostate-specific antigen. 9. http://www. 7. 58:417-424.Screening for prostate cancer. Weiss RE.fcgi?cmd=Retrieve&db=PubMed&list_uids=9586592& dopt=Abstract Roehrborn CG. Fagerstrom RM.ncbi. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=10513131& dopt=Abstract Frank J. Decline in prostate cancer mortality from 1980 to 1997. http://www. Girman CJ. Austria. and an update on incidence trends in Olmsted County. Data from several large-scale studies have led to doubts concerning the role of routine upper urinary tract imaging in patients with LUTS.9. Choong S.fcgi?cmd=Retrieve&db=PubMed&list_uids=12735501& dopt=Abstract Djavan B.ncbi. Colorectal and Ovarian (PLCO) Cancer Screening Trial.nlm. J Urol 2000.ncbi. Popescu V.gov/entrez/query.nlm. 12.gov/entrez/query. particularly a high rate of IVU. 10. 3. Bergstaralh EJ. The most common argument in favour of routine imaging of the upper urinary tract was ‘not to miss anything’. Prostate. http://www.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=10737484& dopt=Abstract Weissfeld JL. and that 16 of 24 centres (67%) used plain films as routine procedures prior to prostatectomy (14). mass screening in the Federal State of Tyrol. Zlotta AR. Klocker H.fcgi?cmd=Retrieve&db=PubMed&list_uids=11189690& dopt=Abstract Roehrborn CG.nlm. Schulman CC. a randomized study comparing the knee-elbow and the left-lateral position.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=11251525& dopt=Abstract 3. Emberton M.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=9915441& dopt=Abstract Schröder FH.gov/entrez/query. Taylor R. has been an integral part of the diagnostic assessment of elderly men with LUTS due to BPH during past decades (1-12). 21(Suppl 6):S390-399. 8.nlm.ncbi.87:331-333. Horninger W. Andrews S. http://www.6.6 Imaging of the urinary tract Imaging of the entire (including the upper) urinary tract. Wilkinson and Wild (12) reported on 175 patients with LUTS with no urinary retention and identified no abnormalities on renal ultrasound and IVU that would have altered the therapeutic 18 UPDATE MARCH 2004 .46:1253-1260. the role of routine imaging of the upper and lower urinary tract in all patients with LUTS has been increasingly questioned in recent years (5.gov/entrez/query. Optimal predictors of prostate cancer in repeat prostate biopsy: a prospective study in 1.57:1087-1092.
3% and 0.0002. Based on several autopsy and epidemiological studies.6. 74. 30% had measurable degrees of renal insufficiency. as well as reproducibility. Hydronephrosis was found in 7. only limited urodynamic information. most of the cancers suspected during imaging were not identified during endoscopy.3 Urethra Retrograde urethrography gives only indirect information on the effect of benign prostatic enlargement (BPE) on adjacent structures.000-200. IVU or renal ultrasound Several arguments support the use of renal ultrasound. and solid renal masses were identified in 0.6. Poor or no renal function was found in 12. Reliable data on inter.1 million patients revealed an incidence of adverse effects due to contrast medium in approximately 6% of patients. at best. post-void residual urine volume and prostate • costs • avoidance of irradiation • no side-effects. and a risk of dying from an allergic reaction of 1 in 100. 14 (2. Manieri et al. respectively.58 rem. The authors concluded that renal ultrasound is only indicated in patients with an elevated serum creatinine level and/or post-void residual urine volume (13). Other malignancies found during routine examination of the urinary tract are bladder and ureteral cancer. the measurement of bladder wall thickness by transabdominal ultrasound has gained considerable interest as a non-invasive tool to assess bladder outflow obstruction (19). A recent review was carried out on data from 25 published reports on the findings of IVU. It is therefore not recommended in the routine diagnostic work-up of elderly men with LUTS. Overall.6.000.4 years (16). Serum creatinine levels appeared to be correlated with dilatation of the renal pelvis. 3.2 Lower urinary tract Urinary bladder voiding cysto-urethrogram This investigation suffers from the fact that the information on the lower urinary tract is only indirect and gives..3% of all IVUs and 70% of all the ultrasound studies performed were normal. A total of 6.51% of IVU and of ultrasonography patients. it has been estimated that the risk of elderly men developing renal cell cancer ranges from 0.5%) had hydronephrosis (13). UPDATE MARCH 2004 19 . an incidence of serious adverse effects in 1 in 1.3%. The average radiation dose is 1. including 778 patients with LUTS due to BPH.approach. More recently. Similar data have been published by Koch et al.131 men from nine ultrasound series were involved. Renal cysts were seen in 4. (20) concluded that bladder wall thickness appeared to be a useful predictor of bladder outlet obstruction.18% to 0. measurement of bladder wall thickness is currently not part of the recommended diagnostic work-up of patients with LUTS. are still lacking and.6% of IVU and 6.18). Furthermore.5% and 15.56%. IVU adverse events A review of 10 reported studies involving over 2. therefore. in patients with pre-existing renal failure. Among the most important are: • better characterization of renal masses • possibility of investigating the liver and retroperitoneum • simultaneous evaluation of the bladder. The mean patient age in these series was 68.81% and 0.000 (17. These data need to be correlated with the incidence of renal cell cancer in the general population. However.8% of ultrasonography patients. 3. These figures are comparable with the results of large-scale studies in elderly men with LUTS and indicate that the incidence of renal carcinoma is not increased in these patients.8%. with a value exceeding that of uroflowmetry. who performed renal ultrasound scans in a consecutive series of 556 elderly men with LUTS.and intra-observer variability. A number of tumours were identified during endoscopy that had been overlooked during imaging. the use of LOCM reduces the risk of nephrotoxicity (18).4 Prostate Imaging of the prostate is performed to assess: • prostate size • prostate shape • occult carcinoma • tissue characterization. Low-osmolar contrast material (LOCM) resulted in a six-fold improvement in safety compared with high-osmolar contrast material (18). usually seen in about 1% of cases. 3.
Blandy JP.fcgi?cmd=Retrieve&db=PubMed&list_uids=731806& dopt=Abstract Marshall V. validation of these data by others is still lacking. Preoperative evaluation of patients with bladder outlet obstruction with particular regard to excretory urography. Jacobsen O.nih. However.11:225-230. Pre-prostatectomy excretory urography: does it merit the expense? J Urol 1980. http://www.ncbi.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=6767041& dopt=Abstract 2.nih. Routine intravenous urograms prior to prostatectomy.ncbi.gov/entrez/query. 20 UPDATE MARCH 2004 . Corrigan MJ. rotational body (single plane. or. Eur Urol 1981.gov/entrez/query. Help or habit? Excretion urography before prostatectomy. Intravenous urography in evaluation of acute retention. Moller I.ncbi.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1131499& dopt=Abstract Morrison JD.fcgi?cmd=Retrieve&db=PubMed&list_uids=74088& dopt=Abstract Bohne AW. Excretory urography: a superfluous routine examination in patients with prostatic hypertrophy. 3.nlm.34:239-241. REFERENCES Andersen JT. 6.nih.nih. Prostatism: how useful is routine imaging of the urinary tract? Br Med J 1988. 9. The prostate volume estimated by DRE and endoscopy is known to underestimate prostates over 40 mL in size (24). This is based on the usual normal triangular-shaped appearance of the prostate in the absence of benign prostatic enlargement (BPE). the shape of the prostate is changed by the continuous growth of the transition zone.nih.nlm. by transabdominal ultrasound. orthogonal plane. Is urography necessary for patients with acute retention of urine before prostatectomy? Br J Urol 1974.ncbi. http://www.nlm. http://www. 7.nlm.120:685-686.fcgi?cmd=Retrieve&db=PubMed&list_uids=6161822& dopt=Abstract DeLacey G. Donnelly B. Pantos TG. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=6158963& dopt=Abstract Pinck BD.86:171-172.gov/entrez/query.23).gov/entrez/query. Jasper P. 3. ellipsoid) and three-dimensional methods (23). Prostate size A large body of evidence documents the accuracy of TRUS in calculating the volume of the prostate (22. Prostate volume can be estimated by serial planimetry.gov/entrez/query. Singh M. http://www.6. Prostate shape Watanabe (25) introduced the concept of the presumed circle area ratio (PCAR).123:390-391.fcgi?cmd=Retrieve&db=PubMed&list_uids=2429536& dopt=Abstract Butler MR. http://www.Choice of imaging modalities The prostate can be imaged using: • transabdominal ultrasound • TRUS • computed tomography (CT) and magnetic resonance imaging (MRI) (including transrectal MRI). Urology 1978. Komaranchat A. Watanabe reported that pathological residual urine is seen if the presumed circle area ratio (PCAR) is greater than 0. rectal examination and or urethral pressure profile (24). More likely causes include bladder cancer or prostate cancer.nlm. Scand J Urol Nephrol 1977.fcgi?cmd=Retrieve&db=PubMed&list_uids=715976& dopt=Abstract Christofferson I. J Urol 1961. http://www. if this is not available.ncbi. http://www. is currently used (21).296:965-967. In BPE.fcgi?cmd=Retrieve&db=PubMed&list_uids=2451969& dopt=Abstract Donker PJ.7:65-67. Kakiailatu F.nlm. The diagnostic value of intravenous pyelography in infravesical obstruction in males.nlm. 4.ncbi. Standgaard L. IVU. Br J Clin Pract 1980.gov/entrez/query.gov/entrez/query. J Urol 1978.ncbi. Johnson S. Excretory urography in patients with prostatism. however. Katz PG. and that BPE is very unlikely to be the cause of the post-void residual urine volume. 10. Mee D. Am J Radiol 1986. 8. 5. http://www. only imaging of the prostate by TRUS.75 or less than 75.147:957-959.nih. Urwiller RD.gov/entrez/query.gov/entrez/query.46:73-76. TRUS has significantly higher accuracy than that of cystoscopy.12:464-466.nih.5 1.nlm.nlm.nih. In daily routine practice. Bundrick TJ.ncbi.
24. Plymouth: Health Publications.nlm.ncbi.gov/entrez/query. The diagnosis of bladder outlet obstruction in men by ultrasound measurement of bladder wall thickness.nlm. http://www. Debruyne FM. 21. 25. Debruyne FM. Transurethral prostatectomy: practice aspects of the dominant operation in American urology.Survey of urological centres and review of current practice in the pre-operative assessment of prostatism.nlm.nlm..ncbi. http://www. 20. Eckmann DR.nih. 17. In: Denis L. Peters PC.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7539178& dopt=Abstract Aarnink RG. de la Rosette JJ. 22. J Urol 1997. Reproducibility of prostate volume measurements from transrectal ultrasonography by an automated and a manual technique.nlm.ncbi.ncbi.ncbi.nlm. Romano G.gov/entrez/query.nih.and low-osmolarity iodinated contrast media.141:248-253.nih.51:19-22. http://www. Valenti M. Accurate determination of prostate size via digital rectal examination and transrectal ultrasound.fcgi?cmd=Retrieve&db=PubMed&list_uids=1379104& dopt=Abstract Holtgrewe HL. Debruyne FM.22:321-332. http://www.ncbi.nlm.ncbi. Noninvasive quantitative estimation of infravesical obstruction using ultrasonic measurement of bladder weight.ncbi.gov/entrez/query.nih.nih. Inui E. de la Rosette JJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=9474143& dopt=Abstract Scheckowitz EM.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9586592& dopt=Abstract Watanabe H. 155:186-189.gov/entrez/query. New concept of BPH: PCAR theory. http://www. Prostate 1998.159:1568-1579. Artibani W. Acta Radiol 1993. The outcome of renal ultrasound in the assessment of 556 consecutive patients with benign prostatic hyperplasia. pp. http://www.nlm. Carter SS. Paris. Wijkstra H. Lapointe S. Radiology 1987.fcgi?cmd=Retrieve&db=PubMed&list_uids=8489830& dopt=Abstract Kojima M.ncbi. J Urol 1989. Br J Urol 1992. http://www. Proceedings of the Fourth International Consultation on BPH. Trucchi A.nlm.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8813917& dopt=Abstract Aarnink RG. High-osmolar and low-osmolar contrast media. Naya Y. 23. http://www. Transrectal ultrasound of the prostate: innovations and future applications. http://www.nlm. J Urol 1998.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490828& dopt=Abstract Wilkinson AG. Wild SR.nih.nih. Imaging of the prostate.159:761-765.nlm. Is pre-operative imaging of the urinary tract worthwhile in the assessment of prostatism? Br J Urol 1992. 19. Ezz el Din K.nih.plymbridge. Dowd JB.fcgi?cmd=Retrieve&db=PubMed&list_uids=8511292& dopt=Abstract Thomson HS.ncbi.ncbi. Benign prostatic hyperplasia. Ochiai A.gov/entrez/query.gov/entrez/query. 15. Khoury S et al. Urology 1998.nih. Carlisle EJ. Meta-analysis of the relative nephrotoxicity of high. Tubaro A.fcgi?cmd=Retrieve&db=PubMed&list_uids=8996337& dopt=Abstract Manieri C. de la Rosette JJ.11. Beerlage HP.70:53-57.ncbi. Proctor C. J Urol 1998.157:476-479. Br J Urol 1996. Watanabe H. Wild SR.gov/entrez/query. http://www. 18.gov/entrez/query. 179-265. Rosel PR. http://www.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=2446348& dopt=Abstract Wilkinson AG.fcgi?cmd=Retrieve&db=PubMed&list_uids=9554357& dopt=Abstract Roehrborn CG.165:831-835. http://www.nih. Assessment of prostatism: role of intravenous urography.nlm. Wasserman NF.nih. http://www. http://www. 14.nih. Mebust WK.nih.34:205-209. eds.fcgi?cmd=Retrieve&db=PubMed&list_uids=1379105& dopt=Abstract Koch WF. 12. 13.gov/entrez/query.nlm.gov/entrez/query. Dorph S.70:43-45.ncbi. 16.37:116-125. Radiology 1993.188:171-178.com/ Barrett BJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=2643720& dopt=Abstract Koyanagi T. July 1997. Urol Clin North Am 1995. Correa R et al. Resnick MI. de Wildt MJ.nih.gov/entrez/query. Wijkstra H. http://www. J Urol 1996. Cockett AT. Ukimura O. Griffiths K.78:219-223.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9759706&query_hl=54&itool=pubmed_docsum UPDATE MARCH 2004 21 .gov/entrez/query.
3. and provides important insights into LUTS.ncbi. http://www. van Venrooij GEPM. Eckhardt MD. Boon TA.164:1201-1205. men with a Qmax less than 10 mL/sec are more likely to have BOO and are therefore more likely to improve with surgery. http://www.nih. Br J Urol 1998. 3. Scand J Urol Nephrol 1996.179:47-53.nlm. Serial flows (two or more) with a voided volume exceeding 150 mL are recommended to get a representative flow rate. Nocturia and polyuria in men referred with lower urinary tract symptoms. such as frequency and nocturia.ncbi. http://www. REFERENCES Abrams P. lower urinary tract symptoms and bladder outlet obstruction. Eur Urol 2001. for example.gov/entrez/query. Osawa D.fcgi?cmd=Retrieve&db=PubMed&list_uids=10368248& dopt=Abstract 2. Yang Q. Analysis and reliability of data from 24-hour frequency-volume charts in men with lower urinary tract symptoms due to benign prostatic hyperplasia.3.82:619-623. Schäfer W. Voiding charts allow. Abrams P.8 Uroflowmetry Uroflowmetry is recommended as a diagnostic assessment in the work-up of patients with LUTS and is an obligatory test prior to surgical intervention.39:42-47. Normal voiding patterns and determinants of increased diurnal and nocturnal voiding frequency in elderly men.fcgi?cmd=Retrieve&db=PubMed&list_uids=10859441& dopt=Abstract Van Venrooij GEPM. and this information should be interpreted by the physician to exclude artifacts (1-3).ncbi. one of the causes of nocturia in elderly men (4-6).2). 22 UPDATE MARCH 2004 . Prins A. A frequency volume chart is non-invasive .7. http://www.nih. Br J Urol Int 1999.nih.1 CONCLUSIONS Recording of a 24-hour frequency volume chart in the course of an initial consultation is considered to be a standard investigation. Men with LUTS and normal Qmax are more likely to have a non-BPH-related cause of their symptoms.gov/entrez/query.ncbi. Flow rate machinery provides information on voided volume. There is a close correlation between LUTS. 6. assessed using a 7-day frequency-volume chart. J Urol 2000.gov/entrez/query.nlm. However.ncbi. http://www. Rittig S.nih.gov/entrez/query.38:45-52. Boon TA.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=11173938& dopt=Abstract Blanker MH.83:1017-1022. BOO can only be diagnosed with a pressure flow study (pQs) (see section 3. There is no standard frequency volume chart available. Dabhoiewala NF. Bosch JLHR. and data generated by voiding charts.nlm. Data from frequency-volume charts versus symptom scores and quality of life score in men with lower urinary tract symptoms due to benign prostatic hyperplasia. Djurhuus JC.10) and flow rates should interpreted with caution in particular as elderly men with LUTS have age-related urodynamic changes (4). 4. http://www. Frequency volume charts: an indispensable part of lower urinary tract assessment. the identification of patients with nocturnal polyuria. The ICS-BPH study: uroflowmetry. non-invasive test that can reveal abnormal voiding. Gisholf KWH.7 Voiding charts (diaries) Voiding charts (diaries) are simple to complete and can provide useful and objective clinical information (1.nlm. It is a simple. However.fcgi?cmd=Retrieve&db=PubMed&list_uids=8908664& dopt=Abstract Reynard JM.nlm. de la Rosette JJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=10992366& dopt=Abstract Matthiesen TB. 3. Eur Urol 2000.nih.7.gov/entrez/query. Mortensen JT. Klevmark B. Peters TL. 5. inexpensive. Lim AT. 3. Bernsen RMD.fcgi?cmd=Retrieve&db=PubMed&list_uids=9839573& dopt=Abstract Gisolf KWH.2 1. Donavan JL.gov/entrez/query.nlm. Eckhardt MD. recent data indicate that a 24-hour voiding chart is sufficient and that longer time periods provide only little additional information (3). maximum flow rate (Qmax). The ICS BPH study reported an exact correlation in 41% of the number of voids.nih. average flow (Qave) and time to Qmax. 61% for the time of voids and 68% for episodes of nocturia (2). Groeneveld FPMJ. Bohnen AM. as assessed by symptom scores.
whereas pressure-flow studies can categorize the degree of obstruction and identify patients in whom a low flow rate may be due to a low-pressure detrusor contraction. Stoner E. and length obtained by transabdominal ultrasonography. Andersen JT. UPDATE MARCH 2004 23 . Klingler HC.8. Zerbib M.ncbi. it is known that patients with high-pressure and low-flow urodynamics have the best outcome from prostatectomy. Cook T. de la Rosette JJ. Maximum urinary flow rate by uroflowmetry: automatic or visual interpretation. Debruyne FMJ.nih. Although pressure-flow studies are the only means of diagnosing obstruction accurately. Computerized artefact detection and correction of uroflow curves: Towards a more consistent quantitative assessment of maximum flow. residual urine is not a contraindication to watchful waiting or medical therapy. (12. Recent methodological studies looking on intra-individual variation in pressure-flow results as well as intra. http://www. individuals with low voided volumes. width.10.nlm. Blaivas JG. J Urol 1993.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7678870&query_hl=71&itool=pubmed_docsum Witjes WP. and because pressure-flow studies are regarded as invasive. 4. Detrusor pressure at the point of maximum flow must be recorded in order to diagnose obstruction.33:54-63.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2956425&query_hl=67&itool=pubmed_docsum Grino PB. the case for pressure-flow studies is stronger. 3.gov/entrez/query. Most work in relation to pressure-flow studies and treatment of LUTS due to BPO relates to TURP.gov/entrez/query.10 Urodynamic studies Pressure-flow studies are regarded as an additional diagnostic test and are considered optional by both the AUA guideline panel on management of benign prostatic hyperplasia (2003) (1) and the Fifth International Consultation on BPH (2). it is not possible to establish a PVR “cut-point” for treatment decision. For this reason. 3. Wijkstra H. Vignoli GC. Flow rates only determine the probability of obstruction. It should be calculated by measurement of the bladder height. Stulnig T. The ICS (International Continence Society) nomogram (11) has now been adopted as the standard nomogram to aid comparison of different data sets. http://www. http://www. Marberger M. 3. based on pressure-flow studies.ncbi. or men with a Qmax of more than 10mL/s. and they all correlate closely. Geffriaud C. Sterling AM.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9471041&query_hl=80&itool=pubmed_docsum Madersbacher S. Abrams et al. Age-related urodynamic changes in patients with benign prostatic hyperplasia. Those developed by Schafer (8). Siroky MB. such as in elderly patients. but the probability is lower. Flow rates may be particularly limited in predicting obstruction in specific situations. James ED. J Med Eng Technol 1987. Urodynamic equipment: Technical aspects.11:57-64.und inter-individual observer accuracy in interpretation of pressure-flow curves have demonstrated a considerable methodological variation (3-6). Suhel PF. http://www. they remain optional. as well as in the presence of neurological disease. Patients with low-pressure and low-flow urodynamics may also have a successful outcome following prostatectomy. Eur Urol 1998. This is a simple.nih. 3.13). Still.nlm.149:339-341. Schatzl G. Because of large test-retest variability and lack of outcome studies. Large PVR volumes (> 200-300 mL) may indicate bladder dysfunction and predict a less favourable response to treatment. REFERENCES Rowan D.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8863566&query_hl=83&itool=pubmed_docsum 2. (14). Schmidbauer CP. (16) and Langen et al. The methodology for performing pressure-flow studies is now standardized (7) and requires simultaneous recording of both intravesical and intra-abdominal pressure. Robertson et al. J Urol 1996. Bruskewitz R. However. This makes it more difficult to judge the influence of infravesical obstruction on lower urinary tract symptoms in patients with BPH. and should be used in clinical practice.nlm.nih.156:1662-1667. In specific patient subgroups.1 1. Abrams and Griffiths (9) and Rollema and Van Mastrigt (URA – Urethral Resistance Index) (10) are most commonly used.ncbi.nih. Jensen (15).gov/entrez/query. (17) all report improved outcomes in patients who are obstructed prior to surgery. Different nomograms exist with which to classify patients into categories of obstruction.1 Outcome Pressure-flow studies do not predict the response to medical therapy and have no role in this setting.9 Post-void residual volume Post-void residual (PVR) urine measurement is recommended during initial assessment. debate continues as to their role in predicting treatment outcomes. Studies reported by Neal et al.3. Kramer AE. accurate and non-invasive method.ncbi.nlm.
July 2000. Neurourol Urodyn 1997. Khoury S. Pressure-flow studies: Short term repeatability. de La Rosette JJ. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=10338441& dopt=Abstract Sonke GS. http://www.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=3427341& dopt=Abstract Neal DE.149:574-577.51:129-134.ncbi. p. Relationship between voiding pressure. Chapter 1: Diagnosis and treatment recommendations. Improved indication and follow-up in transurethral resection of the prostate using the computer program CLIM: a prospective study.fcgi?cmd=Retrieve&db=PubMed&list_uids=12853821& dopt=Abstract Chatelain C.nlm.gov/entrez/query. Test-retest variation of pressure flow parameters in men with bladder outlet obstruction. urethral resistance and urethral obstruction.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=465971& dopt=Abstract Rollema HJ.ncbi. van Mastrigt R. Powell PH.gov/entrez/query. 13. The ICS nomogram should be used for the diagnosis of obstruction in order to standardize data for comparative purposes. http://www.nlm.nih. Berge V.fcgi?cmd=Retrieve&db=PubMed&list_uids=11071695& dopt=Abstract Eri LM. 11. Neurourol Urodyn 2000. Nordling J. Sonke GS.nlm.gov/entrez/query.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=2508914& dopt=Abstract 2. Wessel N.gov/entrez/query.3. 12. Neurourol Urodyn 2000.ncbi.ncbi. Plymouth: Health Publications.gov/entrez/query. Paris. These studies are the most useful investigations available for the purpose of counselling patients regarding the outcome of surgical therapies for BPH. J Urol 2001.nih.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=11257668& dopt=Abstract Kortmann BB.nlm. http://www. Ramsden PD. 24 UPDATE MARCH 2004 . Kallestrup E. J Urol 1992. Standardization of terminology of lower urinary tract function: pressure-flow studies of voiding. 7. http://www. http://www. 2001. http://www.170:530-547. 9. 4. 524.nlm. Outcome of elective prostatectomy. Olsen L. Br J Urol 1979. Sterling AM.nih. Nordling J. Powell PH.nih. symptoms and urodynamic findings in 253 men undergoing prostatectomy.ncbi. Ramsden PD.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9021786& dopt=Abstract Neal DE. Debruyne F. 5.2 CONCLUSIONS Pressure-flow studies remain optional tests in straightforward cases presenting for the first time with LUTS.3 REFERENCES 1.nih. 10.fcgi?cmd=Retrieve&db=PubMed&list_uids=10797579& dopt=Abstract Rowan D. Kiemeney LA.nlm.gov/entrez/query. Holm NR. Proceedings of the Fifth International Consultation on BPH.10. Suhel PF. Rollema HJ.nih. Kortmann BB. AUA practice guideline committee.nlm.18:205-214. Verbeek AL. 8. Griffiths DJ. Sharples L. Urodynamic equipment: technical aspects.nih. 3.fcgi?cmd=Retrieve&db=PubMed&list_uids=2956425& dopt=Abstract Schafer W.nih. J Urol 2003.ncbi. Webb RJ. Produced by the International Continence Society Working Party on Urodynamic Equipment. Hofner K. Styles RA. 3. International Continence Society Subcommittee on Standardization of Terminology of Pressure-Flow Studies.plymbridge. Foo KT.148:111-115. de La Rossette JJ.nlm.60:554-559.gov/entrez/query. Kramer AE. The assessment of prostatic obstruction from urodynamic measurements and from residual urine. Thong J. Neurourol Urodyn 1999.gov/entrez/query. van Mastrigt R.ncbi. http://www. AUA guidelines on management of benign prostatic hyperplasia (2003). Spangberg A. Smith A. Styles RA. Wijkstra H.ncbi.19:637-651.10. Atan A. Variability of pressure-flow studies in men with lower urinary tract symptoms. Intra.11:57-64.16:1-18. A new concept for simple but specific grading of bladder outflow condition independent from detrusor function. McConnell J eds.165:1188-1192. J Urol 1993. http://www.nih. http://www. Denis L. Gleason D.and Inter-investigator variation in the analysis of pressure-flow studies in men with lower urinary tract symptoms.19:221-232.com/ Hansen F. Abrams P.nlm.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1377287& dopt=Abstract Griffiths D.gov/entrez/query.gov/entrez/query. Br J Urol 1987. James ED. http://www.299:762-767.nlm. http://www.ncbi. 6. BMJ 1989. J Med Eng Technol 1987.
121:640-642.1 LUTS caused by bladder outlet obstruction Voiding complaints in elderly men are most frequently caused by BPH resulting in benign prostatic obstruction. All 21 patients who presented with diverticula had an 'obstructive' peak flow rate prior to surgery. indicated by the presence of muscular trabeculation and the formation of cellules as well as diverticula • formation of bladder stones • retention of (post-void residual) urine. (5) evaluated 122 patients of mean age 64 years with LUTS using three post-operative uroflowmetry tests and symptom evaluation.11. the role of BPH in the voiding dysfunction experienced by elderly men is often unclear (1).fcgi?cmd=Retrieve&db=PubMed&list_uids=8558647& dopt=Abstract Langen PH. patency of the bladder neck. (4) studied 85 patients and found that the risk of acquiring clinically significant urinary tract infection was 2.4% after urethral instrumentation alone.gov/entrez/query.3 Relationship between trabeculation and peak flow rate Shoukry et al. BPH may be associated with a relatively small prostate and marked obstructive symptoms if the obstructing tissue originates exclusively within the central zone of the peri-urethral gland area (2). 3. Turner-Warwick RT. Neurourol Urodynam 1989. prostate. Feneley RC. prostatic occlusion of the urethra and estimated prostate size (3).nlm. Abrams PH. size and severity of obstruction. Anikwe (6) showed that there was no significant correlation (p > 0. The results of prostatectomy: a symptomatic and urodynamic analysis of 152 patients.11.4 Relationship between trabeculation and symptoms Simonsen et al. it was noted that trabeculation significantly increased with increasing age (p < 0. as graded from I to IV.nih. Hyperplasia may be associated with striking lateral lobe enlargement. Farrar DJ. 15. Conversely.nlm. 3. The pre-operative peak flow rate was normal in 25% of 60 patients who had no bladder trabeculation. eds.ncbi. Conventional urodynamics and ambulatory monitoring in the definition and management of bladder outflow obstruction.11 Endoscopy The standard endoscopic procedure for diagnostic evaluation of the lower urinary tract (urethra. 3.nih. Urodynamic assessment in patients undergoing transurethral resection of the prostate: a prospective study. and the peak pre-operative flow rate in 39 men aged 53-83 years with LUTS. Robertson AS. 21% of 73 patients with mild trabeculation and 12% of 40 patients with marked trabeculation on cystoscopy. while moderate-to-severe trabeculation was predictive of larger prostate size and reduced flow rate (8). but symptoms may be negligible if the degree of obstruction is not severe. When patients were grouped by age. 1992.2 Morbidity of urethrocystoscopy Berge et al. http://www. Griffiths C. indicating the presence of such obstruction. There appeared to be a trend towards lower peak flow rates in men with higher degrees of trabeculation. none of the trabeculation ratings were predictive of symptom severity. Several studies have addressed these issues. This obstruction has a critical role in altering voiding. 75-84.14..11. 3. Neal DE.ncbi. Jakse G.gov/entrez/query. (7) found a correlation between the presence of trabeculation and the number of obstructive symptoms. Schafer W.155:506-511. http://www. et al. bladder neck and bladder) is a urethrocystoscopy. Urethrocystoscopy was also performed in these patients. This investigation can confirm causes of outflow obstruction while eliminating intravesical abnormalities. Whiteside CG.11. Clinical evaluation of routine urodynamic investigations in prostatism. 17. In another study. J Urol 1996. However. 3. It is generally accepted that therapies aimed at removing obstruction will relieve LUTS in most men.fcgi?cmd=Retrieve&db=PubMed&list_uids=86617& dopt=Abstract Jensen KM-E. J Urol 1979.5) between the degree of trabeculation. These signs may include: • enlargement of the prostate gland with visual obstruction of the urethra and the bladder neck • obstruction of the bladder neck by a high posterior lip of the bladder neck • muscular hypertrophy of the detrusor muscle.5). 16. resulting in significant (pathological) changes in the urinary tract of some patients and symptoms alone in others. New York: Springer-Verlag. Benign Prostatic Hyperplasia: Conservative and Operative Management.8:545-578. In: Jakse G. Thus. pp. urethrocystoscopy may provide information about the cause. Patients with BPH or other forms of bladder outlet obstruction may develop certain signs seen by urethrocystoscopy. UPDATE MARCH 2004 25 .
g. (10) showed that patients had a high likelihood of outlet obstruction when their prostate size was greater than 30 mL or if their posterior urethra was severely obstructed on endoscopy. While it is not always clear whether the obstruction is of an organic. in the case of abnormal urine cytology). The crux of the matter has to be whether or not the detection of bladder stones dictates the surgical procedure of choice. suggesting the inadvisability of drawing the same conclusion in all patients.11. It was concluded that haematuria is a frequent finding in the assessment of BPH patients and that additional tests should only be performed if indicated (e. while approximately 8% of patients have no obstruction at all even if severe trabeculation is present. Equally poorly documented is the impact that the presence or absence of bladder diverticula might have on outcome after prostate surgery. (13). It is. peak flow rate or prostate size. are equally sensitive. However. In fact. It is therefore questionable whether or not urethrocystoscopy should be performed to assess the presence or absence of bladder stones prior to surgery for BPH. or more sensitive.5 Relationship between trabeculation and prostate size Anderson and Nordling (9) examined the correlation between cystoscopic findings and the presence of trabeculation. urinalysis and a cystoscopy were performed in 750 consecutive patients with BPH.11. Quirinia and Hoffmann (12) reported on 104 patients with BPH of whom 51% had diverticula by cystography. There was no correlation between any clinical parameter and the finding of microscopic haematuria. there was no relationship with bladder capacity. 3. no final decision about the value of cystoscopy in the assessment of bladder diverticula can be made. They believe that the value of urethrocystoscopy is limited and advise against its use in the diagnosis of bladder outlet obstruction. upper tract dilation. the presence of stones in the bladder indicates an abnormality in the bladder-emptying mechanism and is usually preceded by the presence of residual urine or recurrent urinary tract infections. Although the presence of diverticula was related to age.5). 3. stones composed of poorly radio-opaque or radiolucent material are seen very well by transabdominal sonography. 3. IVP. Instead. However. (11) evaluated urethroscopic findings and the results of urodynamic studies in 492 elderly men with LUTS.11. It is obvious that the presence of a large bladder stone should guide the surgeon towards an open procedure rather than a lengthy electrohydraulic lithotripsy.3.9 Intravesical pathology The detection of other pathology (urethral or intravesical) is advantageous and can be accomplished by endoscopy better than with most other modalities.6 Relationship between trabeculation and obstruction El Din et al. the majority of all bladder stones are rather small. intravenous pyelography (IVP) or transabdominal sonography. cystoscopy or transabdominal sonography for evaluating large bladder diverticula. however. It should be noted. at detecting large bladder diverticula. 3. or by destroying them with endoscopic instruments prior to washing them out. the bladder neck to verumontanum distance and the cystoscopic appearance of occlusion did not correlate significantly (p > 0. At present. detrusor instability and low compliance.11. Homma et al. Only three patients had a bladder tumour while 49 had urinary calculi. such as cystography.003).8 Bladder stones and obstruction There is no doubt that the presence of bladder stones can be assessed accurately by urethrocystoscopy. and can be removed during TURP through the sheath of the resectoscope.11. particularly as most patients with bladder stones will have microscopic haematuria that will have been detected during the standard basic evaluation. While the cystoscopically estimated weight correlated with the presence of trabeculation (p = 0. In a study by Ezz El Din et al. anatomical or neurogenic nature. there is also no doubt that bladder stones are detected equally well by IVP or by the non-invasive method of transabdominal sonography. while being missed on a renal ultrasound. 26 UPDATE MARCH 2004 . Bladder stones are a clear indicator of bladder outlet obstruction. increasing amounts of residual urine and bladder instability. For example. No data are available to document the sensitivity or specificity of cystography. evident that other diagnostic modalities. the presence of a large bladder diverticulum might dictate the type of intervention. that bladder outlet obstruction is present in approximately 15% of patients with normal cystoscopic findings. it should be used primarily to exclude bladder pathology and to decide between interventional approaches.7 Bladder diverticula and obstruction The detection of large bladder diverticula might be of therapeutic importance. without carrying the risks of invasive urethrocystoscopy. They noted a clear correlation between cystoscopic appearance (grade of trabeculation and grade of urethral obstruction) and urodynamic indices. however.
ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=1191927& dopt=Abstract Anikwe RM. http://www. 4.ncbi. Correlations between clinical findings and urinary flow rate in benign prostatic hypertrophy.14:23-27.isismedical. Jorgensen HS. Pathology of benign prostatic hyperplasia.gov/entrez/query. Dorflinger T.ncbi. 91-104.gov/entrez/query.ncbi.gov/entrez/query. 3.nih. Br J Urol 1975.nlm.11. Cockett AT. Bruskewitz RC. Nordling J. Elhilali MM. II. Susset JG. urodynamic examinations and prostate biopsies in patients with benign prostatic hyperplasia. Gotoh M. http://www. Cancer 1992. pp.5:61-66.61:392-394. Predictability of conventional tests for the assessment of bladder outlet obstruction in benign prostatic hyperplasia.ncbi. 12. Eri LM. 5.fcgi?cmd=Retrieve&db=PubMed&list_uids=8583551& dopt=Abstract Quirinia A.fcgi?cmd=Retrieve&db=PubMed&list_uids=7693606& dopt=Abstract 2. Berge V. http://www. The scope of the problem. Int Urol Nephrol 1993. Hoffmann AL. http://www. UPDATE MARCH 2004 27 . cystometric and urodynamic findings. Kirby R et al.fcgi?cmd=Retrieve&db=PubMed&list_uids=7686980& dopt=Abstract Andersen JT. http://www. Yamaguchi T. Int Surg 1976. Takei M.70(Suppl 1): 275-279. Scand J Urol Nephrol 1980.nlm.nih.nlm.gov/entrez/query. Wijkstra H. Holtgrewe HL. eds. Relationship of symptoms of prostatism to commonly used physiological and anatomical measures of the severity of benign prostatic hyperplasia.nih.gov/entrez/query.15:355-358.155:1018-1022.nlm. Bladder diverticula in patients with prostatism. http://www. http://www. Grayhack JT.fcgi?cmd=Retrieve&db=PubMed&list_uids=1376196& dopt=Abstract Bostwick DG.150:351-358.nlm. J Urol 1993. http://www. Benign prostatic hyperplasia.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=61184& dopt=Abstract Simonsen O. 10. Moller-Madsen B. 7. 11. In: Textbook of Benign Prostatic Hyperplasia.fcgi?cmd=Retrieve&db=PubMed&list_uids=8578262& dopt=Abstract Shoukry I. Norgaard JP. Winfield HN. Kawabe K. Scand J Urol Nephrol Suppl 1995.nlm.ncbi. 6.fcgi?cmd=Retrieve&db=PubMed&list_uids=9535603& dopt=Abstract El Din KE.gov/entrez/query. 3.ncbi.172:95-98. Dutartre D.nih. The significance of age on symptoms and urodynamic and cystoscopic findings in benign prostatic hypertrophy.gov/entrez/query. 1996. Debruyne FM.47:559-566.11. Int J Urol 1998. Urodynamic evaluation of male outflow obstruction.gov/entrez/query.3. Urol Res 1987.nlm. Rosier PF. http://www.nih.nih. J Urol 1996. Siroky B eds. Tveter KJ.11 REFERENCES 1. 8.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=2448939& dopt=Abstract Barry MJ.25:243-247. Lundhus E. The correlation between urodynamic and cystoscopic findings in elderly men with voiding complaints.nlm. Oxford: Isis Medical Media. de Wildt MJ. Role of uroflowmetry in the assessment of lower urinary tract obstruction in adult males.gov/entrez/query.com/ Larsen EH. Complications of invasive. 9. McConnell JD. de la Rosette JJ. The correlation between cysto-urethroscopic.ncbi.gov/entrez/query. Sihelnik SA. http://www.nlm. Clinical Neurourol 1991.ncbi.ncbi.10 CONCLUSIONS Diagnostic endoscopy of the lower urinary tract should be considered an optional test for the following reasons: • the outcomes of the intervention are unknown • the benefits do not outweigh the harm of the invasive study • patients' preferences are expected to be divided.427-443.nih. Prostatism.fcgi?cmd=Retrieve&db=PubMed&list_uids=7375838& dopt=Abstract Homma Y. Krane RJ.nih.nlm. http://www.
particularly in elderly men. Debruyne FM. Prostate size should be assessed when considering open prostatectomy and TUIP. 14. In patients undergoing investigation for LUTS. it should be noted that there is little evidence in the literature to support this conclusion.nlm. 3. Endoscopy is recommended as a guideline at the time of surgical treatment to rule out other pathology and to assess the shape and size of the prostate. Urinalysis may be included in the primary evaluation. 12. The predictive value of microscopic haematuria in patients with lower urinary tract symptoms and benign prostatic hyperplasia. the use of I-PSS is recommended because of its worldwide distribution and use. or a current. The method of choice for the determination of prostate volume is ultrasonography. 9.ncbi.13. 6. 11. However. In straightforward cases presenting for the first time with LUTS.12 1. which may have an impact on the treatment modality chosen. 7. CT and MRI currently have no place in the routine imaging of the upper urinary tract in elderly men with LUTS. pressure-flow studies should be considered before surgical intervention. urinary tract infection • History of urolithiasis • History of urinary tract surgery • History of urothelial tumour (including IVU) • Haematuria (including IVU) • Urinary retention. de Wildt MJ. 8. ultrasonography is the method of choice. < 50 years of age) • elderly patients (i. Post-void residual urine measurement is recommended during initial assessment. Ultrasound of the bladder. 4. Koch WF. There is a consensus that if imaging of the upper urinary tract is performed. pressure-flow studies remain optional tests.fcgi?cmd=Retrieve&db=PubMed&list_uids=8977059& dopt=Abstract 3. preferably via the transrectal route. > 80 years of age) • post-void residual urine volume over 300 mL • Qmax more than 15 mL/s • suspicion of neurogenic bladder dysfunction • after radical pelvic surgery • previous unsuccessful invasive treatment. de la Rosette JJ. however. 16. is a valuable diagnostic tool for the detection of bladder diverticula or bladder stones. the minimal requirement is to assess the upper urinary tract function with a creatinine measurement and/or an ultrasonographic examination. 15. Ezz el Din K. 13.gov/entrez/query. http://www. If the voided volume is less than 150 mL or Qmax is greater than 10 mL/s. Routine imaging of the urinary bladder cannot be recommended as a diagnostic test in the work-up of patients with LUTS. Imaging of the upper urinary tract is recommended in patients with LUTS and one of the following: • History of. 2.nih. Measurement of residual urine volume is a recommended test in the assessment of patients with LUTS suggestive of benign prostatic obstruction. Routine imaging of the urethra is not recommended in the diagnostic work-up of patients with LUTS. 5. However. RECOMMENDATIONS FOR ASSESSMENT Among all the different urinary symptom score systems currently available. Eur Urol 1996.30:409-413.e. DRE is a minimal requirement in patients undergoing investigation for LUTS. and prior to finasteride therapy.g. imaging of the prostate by transabdominal ultrasound and TRUS is optional. Uroflowmetry is recommended as a diagnostic assessment in the work-up of patients with LUTS and is an obligatory test prior to surgical intervention. Pressure-flow studies should be considered for patients prior to surgical treatment in the following subgroups: • younger men (e. 10. 28 UPDATE MARCH 2004 .
• bladder re-training.a policy of care that has been called watchful waiting (WW). mobility or mental state.1 Patient selection All men with LUTS should be formally assessed prior to starting any form of management in order to identify those with complications that may benefit from intervention therapy. 4. 4. • use of relaxed and double-voiding techniques. by which men are encouraged to ‘hold on’ when they have sensory urgency to increase their bladder capacity (to around 400 mL) and the time between voids. Lifestyle advice should include: • reduction of fluid intake at specific times aimed at reducing urinary frequency when most inconvenient. The reason why some men deteriorate with WW and others do not is not well understood. periodic monitoring and lifestyle advice. It is customary for this type of management to include the following components: education. Men with mild to moderate uncomplicated LUTS (causing no serious health threat) who are not too bothered by their symptoms are suitable for a trial of WW. reassurance. Anxiety regarding prostate cancer can be the principal reason why a man consults his doctor about his urinary symptoms. • information about prostate cancer is nearly always required. breathing exercises. • avoidance or moderation of caffeine and alcohol which may have a diuretic and irritant effect. Symptom scores.4.2). In many men it is regarded as the first tier in the therapeutic cascade and therefore the majority of men will be offered watchful waiting at some point. 36% crossed over to surgery in 5 years leaving 64% doing well in the WW group (4). Reassurance that serious complications are unlikely to occur. if left untreated. The recommended total daily fluid intake of 1500 mL should not be reduced. At least three high-quality studies have shown that men with LUTS are at no greater risk of prostate cancer than asymptomatic men of the same age (7-9). If these men harbour an anxiety about prostate cancer.1. UPDATE MARCH 2004 29 . perineal pressure and mental ‘tricks’ to take the mind off the bladder and toilet in the control of irritative symptoms. reassurance and periodic monitoring Although there is little high quality evidence to support this (the studies have not been done) it seems rational to provide the following for men who are candidates for WW: • prostate. • urethral stripping to prevent postmicturition dribble. It is however not possible to guarantee against early undetectable prostate cancer. will progress to acute urinary retention and complications such as renal insufficiency and stones (1.3 Lifestyle advice Optimization of WW can be achieved with lifestyle modifications. increasing symptom bothersomeness and post-void residual volumes appeared to be strongest predictors of failure. urgency and nocturia.2 Education. for example at night or when going out in public.1. thereby increasing fluid output and enhancing frequency.6). deteriorating progressively to 65% at 5 years (5. A large study comparing WW and TURP in men with moderate symptoms showed that those who had surgery had improved bladder function over the WW group (flow rates and post void residual volumes) with the best results being in those with high levels of bother. flow rates and post-void residual volume measurements are useful in determining whether a patient’s condition has deteriorated.1 TREATMENT Watchful waiting Many men with LUTS do not complain of high levels of bother and so are suitable for non-medical non-surgical management . BPH and LUTS education with the help of written information • reassurance that LUTS does not progress in everyone. Minor changes in lifestyle and behaviour can have a beneficial effect on symptoms and may prevent deterioration requiring medical or surgical treatment.1. this may focus their attention on specific symptoms and reinforce their fear. such as penile squeeze. 4. • reviewing a man’s medication and optimising the time of administration or substituting drugs for others that have fewer urinary effects. WW is a viable option to many men as few. men should be periodically seen by either a urologist. Most men over 50 will note changes in their urinary function with or without high levels of bother. 4. • WW does not imply no activity. • providing necessary assistance when there is impairment of dexterity. Similarly some men’s symptoms may improve spontaneously whilst others remain stable for many years (3). symptom bothersomeness. Approximately 85% of men will be stable on WW at 1 year. general practitioner or specialist nurse. • distraction techniques.
Dalkin BL et al. Prostate 1990.ncbi.2. Wasson JH Anderson RJ.1 5-alpha reductase inhibitors 4. http://www. Ahmann FR.2 Medical treatment 4.nlm. http://www. 4. 8.gov/entrez/query. New Engl J Med 1995.1 Efficacy and clinical endpoints Today. after the completion of many trials. it improves symptom scores by approximately 15% and can also cause a moderate improvement in the urinary flow rate of 1.3-1.nih. http://www. The natural history of untreated ‘prostatism’.15:1283-1290. Netto MR. REFERENCES Ball AJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=7512659& dopt=Abstract Mettlin C. 5-alpha reductase inhibitor) 4.53:613-616. 2. Flanigan RC.nih. 3. the efficacy of 5-alpha reductase inhibitors is unquestionable and has been demonstrated over large clinical trials. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicentre clinical trial of 6. Br J Urol 1981.fcgi?cmd=Retrieve&db=PubMed&list_uids=6172172& dopt=Abstract Kirby RS.nlm. 4.4 CONCLUSIONS Men with mild to moderate LUTS with low levels of bother are suitable for WW. Elinson J.6 mL/s (1-4). http://www.56:3-6.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9628595& dopt=Abstract Wasson JH.fcgi?cmd=Retrieve&db=PubMed&list_uids=1689166& dopt=Abstract Flanigan RC. 5.3(Suppl):1-7.332:75-79.nlm. The results of a five-year early prostate cancer detection intervention. Murphy GP. Reda DJ. Bruskewitz RC.ncbi. Importance of the natural history of benign prostatic hyperplasia in the evaluation of pharmacologic intervention.1.1. 9. 5-year outcome of surgical resection and watchful waiting for men with moderately symptomatic BPH: a department of Veterans Affairs cooperative study. 30 UPDATE MARCH 2004 .1.nlm.ncbi. Richie JP. J Urol 1994. Hudson MA.1.1 Finasteride (type 2.gov/entrez/query. Scardino PT. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. J Urol 1997. Ratliff TL. 6.fcgi?cmd=Retrieve&db=PubMed&list_uids=7527493& dopt=Abstract Netto NR Jr.• treatment of constipation.160:12-16.nlm.ncbi. 4.gov/entrez/query.nih.nih. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. Reda DJ. http://www. Abrams PH.fcgi?cmd=Retrieve&db=PubMed&list_uids=8630923& dopt=Abstract Rietenberg JBW.53:314-316.630 men.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933046& dopt=Abstract Catalona WJ. Reassurance. Bruskewitz RC. J Urol 1998.2.gov/entrez/query. Cancer 1996. http://www.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=11074195& dopt=Abstract Isaacs JT.1.77:150-159. Kranse R.nih. Feneley RC.157:467. http://www. periodic monitoring and lifestyle modifications can be used to optimise WW. Again it must be stated that there is little high-quality evidence that provides reliable information on any of these lifestyle activities. 4. Keller AM.gov/entrez/query. The natural history of benign prostatic hyperplasia: what have we learned in the last decade? Urology 2000. It can reduce the size of the prostate gland by 20-30%.ncbi.ncbi. Evaluation of patients with bladder outlet obstruction and mild international prostate symptom score followed up by watchful waiting.nlm. American Cancer Society National Prostate Cancer Detection Project.gov/entrez/query. Henderson WG.nih.ncbi. 7.5 1.nlm.nlm.2. D’Ancona CA. Babaian RJ. Urol 1999. http://www. Boeken Kruger AE et al. Kavoussi LR. Further research in this area is required. Research in this area is required so that lifestyle advice to men with LUTS can be refined. Additional value of the AUA 7 symptoms score in prostate cancer (PC) detection.gov/entrez/query.ncbi.gov/entrez/query. de Lima ML. deKernion JB.
22) verified earlier reports. breast enlargement and breast tenderness (9). In a recent publication from the PLESS study group it was shown that the finasteride-related sexual adverse experiences occurred mainly during the first year of therapy (18). multicentre. In a recently published study it was also shown that dutasteride UPDATE MARCH 2004 31 . improve symptoms and urinary flow rate and reduces also the incidence of acute urinary retention and BPH related surgery. All these figures were higher than those observed for placebo. 4.2 Dutasteride It is known that finasteride suppresses dihydrotestosterone (DHT) by about 70% in the serum and by 90% in the prostate.2. In a major placebo controlled trial including 3. double-blind clinical trials have been presented (28. the Scandinavian Finasteride Study Group has verified an earlier observation that the maximum efficacy of finasteride action is obtained after 6 months. impotence (8. Finally it has also been shown that the four year inhibition of type 2 5alpha-reductase with finasteride does not adversely affect bone mineral density (20).222 men. at the same time.1. Dutasteride is a new drug that has the ability to suppress both type 1 and type 2 isoenzymes and as a consequence serum DHT decreases by about 90% (26). Various trials have concluded that finasteride significantly reduced acute urinary retention and the need for surgical treatment in men with BPH (6-8). Three of these studies were placebo controlled studies and they showed that dutasteride can reduce prostatic volume by almost 26%. In the PLESS study the side effects reported were decreased libido (6.1. Thus.1.040 men.2. A phase II study including 399 patients showed that dutasteride can cause greater suppression of DHT than finasteride (27). 4. or enlarged prostate glands.1. In one paper.2 Haematuria and finasteride Another important benefit of finasteride in common clinical urological practice is that it can be used to treat haematuria associated with BPH. The remaining DHT is the result of type 1 5-alpha reductase activity. and concluded that doubling the PSA level allowed appropriate interpretation of PSA values and that finasteride treatment did not mask the detection of prostatic adenocarcinomas. The long-term effects of finasteride have also been examined. In addition. Data from three multinational.1.2. A recent North American study has also verified that long term (10 year) treatment is well tolerated and results in durable symptom relief (13). 4.7%) and in less than 1% of the patients other disorders such as rash. decreased ejaculate (3. and has shown that this improvement could be maintained for at least 6 years (12). finasteride-treated patients had significantly less bother. had no significant obstruction or adenocarcinoma of the prostate (14-17).3 Side-effects These are mainly related to sexual function.A meta-analysis of six randomized clinical trials showed that baseline prostate volume was a key predictor of various treatment outcomes and that finasteride was more effective in prostates larger than 40 mL (5).29). so that the ratio of free PSA to total PSA remained unchanged (24). placebo-controlled finasteride trials. The fourth compared dutasteride with finasteride for one year which showed that drug related adverse events were similar for both compounds. 4. finasteride had the same safety profile and no drug interactions of clinical importance were observed (19). The North American Finasteride Study Group reported that patients treated with finasteride maintained a reduction of prostate volume and an improvement in symptom score and maximal urinary flow rate over a period of 5 years (11). The results of four large randomized. It has been agreed that 12 months of finasteride.4 ng/mL. that finasteride did not cause problems in the diagnosis of cancer from needle specimens as cancer tissue remained unaltered (23).4%). could predict the best long-term response to finasteride (9). ejaculatory disorders and gynecomastia (28). 5 mg/day. In another report. the percentage of free PSA did not change significantly (25). The results of papers dealing with the impact of finasteride on free PSA level are confusing. in 4. the question of whether or not it masks the early detection of localized prostatic adenocarcinomas has been raised.1. Baseline PSA levels of 1. Pooled data from the patients enrolled in all four studies proved that dutasteride is well tolerated and adverse events included erectile dysfunction. activity interference and worry due to urinary symptoms. Such side-effects are considered ‘minimal’ since they did not increase over time and did not cause many patients to discontinue their treatment.4 Effect on PSA It is known that finasteride lowers serum PSA levels.1. finasteride seemed to lower total and free PSA levels equally. Various studies have confirmed this alternative for patients with haematuria due to BPH who. Another conclusion from the PLESS study was that in both older and younger men with symptomatic BPH. reduces serum PSA levels by 50%. showed that patients with larger prostate volumes or higher PSA levels have an increased risk of developing acute urinary retention and therefore derive the greatest benefit from finasteride therapy (10). at the histopathological level. It was also shown. Two major studies (21.1%).2.
and in reducing the likelihood of acute urinary retention and surgery. Andriole GL.155:1251-1259. however. Lehtonen T. in increasing median maximal flow rates. Bracken B.ncbi. Cook T.The combination therapy was superior to either drug alone in reducing AUA symptom scores. 3.1. Imperato-McGinley J. et al. N Engl J Med 1992.nih. Johansson JE. No additional benefit from combining these two drugs was observed in either study. http://www. http://www. on the short term combination of dutasteride and tamsulosin involving 327 patients confirmed compatible results (35). Bracken BR. Geller J.nih. should be further evaluated. The Scandinavian BPH study group.gov/entrez/query.2. placebo-controlled study (SMART study). Walsh PC. Pommerville PJ. it was shown that patients with lower urinary tract symptoms and moderately enlarged prostates initially receiving combination therapy with finasteride and an alpha-blocker were likely to experience no significant symptom deterioration after discontinuing the alphablocker following 9 to 12 months of combination therapy (34). The lack of finasteride efficacy in these two trials may be due to smaller baseline prostate volumes. Daurio C.5 years and another conclusion drawn from this study was that finasteride needs time to reveal its beneficial therapeutic capacity. Waldstreicher J.nih. • Men with small prostates (< 40 mL) are less likely to benefit from finasteride. Efficacy and safety of finasteride therapy for benign prostatic hyperplasia: results of a 2-year randomised controlled trial (the PROSPECT Study). placebo-controlled clinical trials that 5-alpha reductase inhibitors are capable of reducing prostate volume and improving symptom scores and flow rates. Maximum benefits are seen at a mean period after 6 months. Bruskewitz RC.gov/entrez/query. McConnell J. Stoner E. have shown that the combination of finasteride to doxazocin was beneficial (33). The effect of finasteride in men with benign prostatic hyperplasia.1.nlm. By doubling PSA serum levels.gov/entrez/query.2. Recently the results of a multicentre randomized.60:1040-104.nlm. Tenover JS. Stoner E. http://www. In another study examining combination therapy. an accurate estimation can be expected.is associated with clinically significant improvement in BPH specific health status as measured by the BPH Impact Index (BII) (30). Afridi SK. Imperato-McGinley J. • The combination of a 5-alpha reductase inhibitor with an alpha-blocker seems beneficial according to the data currently available. • 5-alpha reductase inhibitors can alter the natural history of symptomatic BPH by influencing prostatectomy and acute urinary retention rates.alpha reductase inhibitors are substantial. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=1383816& dopt=Abstract Nickel JC.327:1185-1191. The costs of such protocols. McConnell JD. Kontturi M. Andersen JT. Matsumoto AM. Tveter K.ncbi.ncbi.46:631-637. Perreault JP. Dutasteride shows similar efficacy and tolerability as finasteride in suppressing both type 1 and type 2 isoenzymes but further randomized studies are needed. 4. Beisland HO. Urology 1995.1. A multicentre. Elhilali MM. Urology 2002. 32 UPDATE MARCH 2004 . Boake RC.4 CONCLUSIONS • It has been shown in numerous randomized.5 REFERENCES 1.gov/entrez/query. Sullivan M. Long-term (7 to 8-year) experience with finasteride in men with benign prostatic hyperplasia. • Side-effects of 5-alpha reductase inhibitors are minimal • Treatment with 5-alpha reductase inhibitors does not mask the detection of prostate carcinoma. Can Med Assoc J 1996. 4. Fradet Y. placebo-controlled double-blinded trial (MTOPS trial).2. [Symptom Management After Reducing Therapy]. The Finasteride Study Group.nih. Roy J. Wolf H. 4. 4.ncbi. The follow-up period of the MTOPS trial was 4.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7495111&query_hl=2&itool=pubmed_docsum Gormley GJ.nlm. Pappas F. • The long-term (up to 10 years) effects of 5. Meeha A. Ekman P.fcgi?cmd=Retrieve&db=PubMed&list_uids=12475666& dopt=Abstract 2. Can finasteride reverse the progress of benign prostatic hyperplasia? A two year placebo-controlled study.32).fcgi?cmd=Retrieve&db=PubMed&list_uids=8911291& dopt=Abstract Vaughan D.3 Combination therapy The combination of finasteride with an alpha-blocker was examined earlier in two clinical trials (31.
fcgi?cmd=Retrieve&db=PubMed&list_uids=9187688& dopt=Abstract McConnell JD. Urology 1997. N Engl J Med 1998. Narayan P. Meehan A. 13. 8. Malice MP. J Urol 2000. 15. Elhilali M. http://www. Kozlowski D. 6.gov/entrez/query.A. Waldstreicher J. Eur Urol 1998. Wang D. 10.gov/entrez/query. http://www. Fusilier H.ncbi. Brown BT. Kashif KM. Bruskewitz R. Waldstreicher J. UPDATE MARCH 2004 33 .fcgi?cmd=Retrieve&db=PubMed&list_uids=10647664& dopt=Abstract Foley SJ. Holmes SA. Finasteride Long-term Efficacy and Safety Study Group. http://www. Lieber M. Bracken R. Wang DZ. http://www.nih. Prostate volume predicts the outcome of treatment of benign prostatic hyperplasia with finasteride: meta-analysis of randomized clinical trials. Malek GH. Bruskewitz R.gov/entrez/query. Basketter V. Long-term treatment with finasteride in men with symptomatic benign prostatic hyperplasia: 10-year follow-up.ncbi. Wedderburn AW.fcgi?cmd=Retrieve&db=PubMed&list_uids=9475762& dopt=Abstract Roehrborn CG. Kornitzer G. Maximum efficacy of finasteride is obtained within 6 months and maintained over 6 years. Nickel JC. Holmes SA.fcgi?cmd=Retrieve&db=PubMed&list_uids=10197842& dopt=Abstract Ekman P.fcgi?cmd=Retrieve&db=PubMed&list_uids=10765090& dopt=Abstract Bruskewitz R. PLESS Study Group. http://www. Walsh P. 9. Wedderburn AW. Soloman LZ.D. http://www. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Bruskewitz RC.ncbi. Urology 1999.gov/entrez/query. Stoner E. Trachtenberg J. Nickel JC. Summerton D. Perreault JP.nlm. Anderson R. Rosenblatt S.ncbi. 12. http://www. Boyle P. Marshall VR. Romas NA. Geller J. Lowe FC. 11.nlm. Kantor S.38:563-568. The North American Finasteride Study Group.48:398-405.163:496-498.nlm. Proscar Long-term Efficacy and Safety Study. Norman R. Gabriel M.ncbi. The Scandinavian Finasteride Study Group. Nickel GC. Combined experience from three large multinational placebo-controlled trials. Girman CJ.nlm. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride. Prostate volume and serum prostate-specific antigen as predictors of acute urinary retention.nih. Andersen JT. Summerton D.nih.ncbi.ncbi. Follow-up of the Scandinavian Open-extension Study. Urology 1999. Holtgrewe HL.49:839-845. Roehrborn CG.nlm.338:557-563. The PLESS Study Group. Characterization of patients and ultimate outcomes. Waldstreicher J. Waldstreicher J.B.gov/entrez/query. Taylor AM.L. Sullivan M. Fowler J. http://www. Pappas F. Urology 2003. Johnson E.164:1670-1671. Schulman CC. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride.37:528-536.33:312-317. Boyle P.nlm.nih. Finasteride significantly reduces acute urinary retention and need for surgery in patients with sympomatic benign prostatic hyperplasia. Andriole G. J Urol 2000.53:690-695.nlm.nlm.gov/entrez/query. Roy JB. http://www.61:354-8. Basketter V. Lieber MM. http://www.nlm. Cox C.ncbi. Soloman LZ. Urology 1996.nih. Eur Urology 2000. Taylor A. Gould AL. Kashif KM. Ko A.fcgi?cmd=Retrieve&db=PubMed&list_uids=10510926& dopt=Abstract Marberger MJ.nlm.F.gov/entrez/query. Kandzari S. Patterson L. Jacobsen CA. Stoner E.nih.Effect of finasteride on bother and other healthrelated quality of life aspects associated with benign prostatic hyperplasia. Efficacy of finasteride is maintained in patients with benign prostatic hyperplasia treated for 5 years.nih. Herlihy R. 7. Roehrborn CG.nih. Eur Urol 2000. Nickel JC. Urinary retention in patients with BPH treated with finasteride or placebo over 4 years.gov/entrez/query.ncbi.nih. Wang D.fcgi?cmd=Retrieve&db=PubMed&list_uids=9555559& dopt=Abstract Lam JS.nih.gov/entrez/query. 14.fcgi?cmd=Retrieve&db=PubMed&list_uids=8804493& dopt=Abstract Andersen JT.fcgi?cmd=Retrieve&db=PubMed&list_uids=12597947& dopt=Abstract Foley SJ.ncbi. Albertsen P. Romas NA. Glickman S.fcgi?cmd=Retrieve&db=PubMed&list_uids=11096237& dopt=Abstract Hudson PB.Z. Rigby O.5.gov/entrez/query.4:670-678. Holtgrewe HL. Boake R.
nlm. Schellhammer PF.nih.ncbi. Tenover L. 18. Narayan P. Grayhack J. Lagerkvist M.nlm. Parra R. Roy J. Shery ED. Bruskewitz R. Bingham JB. 17.gov/entrez/query.gov/entrez/query. Epstein JI. http://www. Proscar Long-term Efficacy and Safety Study. Schmidt J.50:13-18. http://www. J Urol 1998.nlm. McClung M. Rouse S.gov/entrez/query.gov/entrez/query. Pearson JD. 22. Krarup T. Sullivan M. Culbertson J.nih. Dihydrotestosterone and the concept of 5 alpha – reductase inhibition in human benign prostatic hyperplasia. 20. Rittmaster RS. 25. Influence of finasteride on free and total serum prostate specific antigen levels in men with benign prostatic hyperplasia. PLESS Study Group.52:195-201. Barbalias G.gov/entrez/query.gov/entrez/query. Bergland R. Gormley G. PLESS Study Group. Peterson L. Clinical predictors in the use of finasteride for control of gross hematuria due to benign prostatic hyperplasia. Waldstreicher J. 24.fcgi?cmd=Retrieve&db=PubMed&list_uids=9649261& dopt=Abstract Bartsch G. Urology 2002.nlm. Ratliff TL.ncbi. http://www.nih.nlm. Bannow J.fcgi?cmd=Retrieve&db=PubMed&list_uids=11377309& dopt=Abstract Matsumoto AM.ncbi. http://www. Markou S. Bach MA. Geller J.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9697781& dopt=Abstract Yang XJ. Epstein JL. Herlihy R.ncbi. PLESS Study Group. Lee M. Parra R. 23.nlm. Urology 1999.fcgi?cmd=Retrieve&db=PubMed&list_uids=11956450& dopt=Abstract Oesterling JE. The long-term effect of specific type II 5alpha-reductase inhibition with finasteride on bone mineral density in men: results of a 4-year placebo controlled trial. Gormley GJ. Urology 2003. 26.nlm. controlled study.gov/entrez/query. Roy J.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=10197843& dopt=Abstract Keetch DW.fcgi?cmd=Retrieve&db=PubMed&list_uids=9426721& dopt=Abstract Pannek J. randomized.nlm. Lecksell K.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=12022710& dopt=Abstract 34 UPDATE MARCH 2004 . Hudson P.167:2105-2108.gov/entrez/query. J Urol 2002. Matsumoto AM. Mobley D.fcgi?cmd=Retrieve&db=PubMed&list_uids=12639651& dopt=Abstract Kaplan SA.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9218012& dopt=Abstract Andriole GL. 21. terazosin or watchful waiting.ncbi. Puchn PJ. Klocker H.fcgi?cmd=Retrieve&db=PubMed&list_uids=11880073& dopt=Abstract Wessells H. Rajfer J. Incidence and severity of sexual adverse experiences in finasterides and placebo-treated men with benign prostatic hyperplasia. World J Urol 2002. Short K. Proscar Long-term Efficacy and Safety Study.gov/entrez/query.nlm. Catalona WJ.57:1073-1077. Guess HA. Biologic variability of prostate specific antigen and its usefulness as a marker for prostate cancer: effects of finasteride. Shown T. Meade-D’Alisera P. Fitch W. Grayhack J. placebo-controlled clinical trial. Waldstreicher J. Andriole GL. Comparison of the efficacy and safety of finasteride in older versus younger men with benign prostatic hyperplasia.nlm. Cook TJ. Wessells H. Bannow J. http://www.nlm. Urology 1997. Cook TJ.nih. Flanagan M. http://www. Waldstreicher J. Gottesman J. Fitch WP.ncbi. Holtgrewe HL. Chan DW. Urology 1998.159:449-453. http://www. J Urol 2002. Waldstreicher J. Kelley CA. Waldstreicher J. Taylor AM.ncbi.19:413-425. Lee M. Auerbach S. Gyftopoulos K.fcgi?cmd=Retrieve&db=PubMed&list_uids=11992064& dopt=Abstract Perimenis P. Labasky R.59:373-377.ncbi. Mobley D.nih. Stoner E. Kadmon D.53:696-700.167:2489-2491. Jackson CL.ncbi. double-blind. Agha A. 19. Wells G. http://www.16. http://www. Patterson L. Bach M.61:579-584. Tenover L. Does long-term finasteride therapy affect the histologic features of benign prostatic tissue and prostate cancer on needle biopsy? PLESS Study Group.nih. Zhang GK. The Finasteride PSA Study Group. Subong EN. Wise H. http://www.gov/entrez/query. Meehan A.nih.nih. Lund RH. http://www. Kadmon D. Johansen T. Weiner S. Saltzman B. Romas NA. Marks LS. Partin AW.nih. Kearney MC. Urology 1997.ncbi. Hodge GB. Rittenhouse HG. Crawford ED. Comparison of percent free prostate specific antigen levels in men with benign prostatic hyperplasia treated with finasteride.50:901-905. Effects of finasteride and cyproterone acetate on hematuria associated with benign prostatic hyperplasia: a prospective. Waldstreicher J. Urology 2001. Treatment with finasteride preserves usefulness of prostate specific antigen in the detection of prostate cancer: results of a randomized.
gov/entrez/query. The long term effects of medical therapy on the progression of BPH: Results from the MTOPS trial. Kirby R Safety and tolerability of the Dual 5 alpha-Reductase Inhibitor dutasteride in the treatment of benign prostatic hyperplasia.nih. Alpha-blocker therapy can be withdrawn in the majority of men following initial combination therapy with the dual 5alphareductase inhibitor dutasteride. finasteride.nih. Wilson T. 4.27.fcgi?cmd=Retrieve&db=PubMed&list_uids=12887480& dopt=Abstract Lepor H. This increase has been driven partly by patients wishing to achieve symptomatic relief without undergoing surgical treatments and partly by the marketing of these drugs by pharmaceutical companies. they all have a similar efficacy and side-effect profile.44:461-466. Geffriaud-Ricouard C.ncbi. Williford WO.nlm. the sideeffect profile.1 Uroselectivity Alpha-blockers were first introduced into clinical practice for the treatment of LUTS secondary to BPH in 1978.nih. Gabriel H.335:533-539. Delauche-Cavallier MC. Guimaraes M.2. Eur Urol 1998. Efficacy and safety of a dual inhibitor or 5-alphareductase types 1 and 2 (dutasteride) in men with benign prostatic hyperplasia.167:265. Effective suppression of dihydrotestosterone (DHT) by GI 198745. European ALFIN Study Group. van Vierssen Trip OB. J Urol 1999. Colloi D. Gormley G. Boyle P. Morril B. http://www. http://www. In view of the very real placebo effect seen in the treatment of patients with LUTS secondary to BPH. Jardin A. alpha1adrenoceptors were identified and selective. Sustained-release alfuzosin. Witjes WP. Resel L. Baldwin KC.nlm. placebo-controlled clinical studies. alfuzosin. the non-selective alpha-blocker. A large number of alpha1-selective.2 Alpha-blockers Over the past 10 years.fcgi?cmd=Retrieve&db=PubMed&list_uids=12814679& dopt=Abstract O’Leary MP.60:434-441. Nickel C.ncbi.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=12350480& dopt=Abstract Andriole GL.gov/entrez/query.2.nlm. the novel dual 5 alpha-reductase inhibitor. 33. Brawer MK. Dixon CM. was unacceptable to patients (2. the prescribing of alpha-blockers has steadily increased. 34.ncbi. Subsequently. Boyle PJ. Hofner K. Benign Prostatic Hyperplasia Study Group.nlm. On behalf of the ARIA3001.nlm. Hermann D. terazosin). http://www. 28.3). alpha-blockers are available (tamsulosin. Roehrborn C.fcgi?cmd=Retrieve&db=PubMed&list_uids=8684407& dopt=Abstract Debruyne FM. 35. 31. Hobbs S. Jacobi G. 32. Eur Urol 2003.fcgi?cmd=Retrieve&db=PubMed&list_uids=9732187& dopt=Abstract Mc Connell JD. http://www. phenoxybenzamine.nih. Roehrborn CG. Discontinuation of alpha-blockade after initial treatment with finasteride and doxazosin in men with lower urinary tract symptoms and clinical evidence of benign prostatic hyperplasia.2. Urology 2002. Improvements in benign prostatic hyperplasia-specific quality of life with dutasteride. Eur Urol 2003. Veterans Affairs Cooperative Studies. or both in benign prostatic hyperplasia. http://www. Padley RJ. http://www.58:203-209.92:262-265. indoramin. Pushkar D. Barry MJ. Hoefner K.gov/entrez/query. Andriole G.44:82-88. McCarthy C.gov/entrez/query. BJU Inter 2003. prospective. Clarke R. this review will focus on the results of randomized. Andriole GL. http://www. Roehrborn CG. Initially. alpha-blockers were developed.ncbi. finasteride and the combination of both in the treatment of BPH. Nickel C. 29. Urology 2001.ncbi.ncbi.ncbi.34:169-175. better-tolerated.nlm. J Urol 2002. was investigated. Harkaway RC. dual 5-alpha reductase inhibitor.gov/entrez/query.nih. 30. abstract 1042. Taylor S. doxazosin.fcgi?cmd=Retrieve&db=PubMed&list_uids=11489700& dopt=Abstract Barkin J. following experimental work demonstrating the predominance of adrenoceptors in human prostate smooth muscle (1). However.161:1037. a novel.nlm. Haakenson C.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract& list_uids=14499682 4. Narayan P. Broadly speaking. due to its unselective nature.gov/entrez/query. UPDATE MARCH 2004 35 . The efficacy of terazosin. N Engl J Med 1996. Machi M.nih. ARIA3002 and ARIA3003 study investigators.gov/entrez/query. prazosin. Ginsberg PC.
Tamsulosin resulted in less orthostatic hypotension than alfuzosin under test conditions. Patients may choose to stop taking medication for a number of reasons. drowsiness. once-daily preparations. 4. 4. In general. There is no justification in prolonging therapy beyond one month in men who do not respond.2. Studies are underway which address the question of whether men do benefit from alpha-blockade in the six months following acute urinary retention. namely.7 Adverse effects The most commonly reported side-effects with alpha-blocker therapy are headaches.6 per month. 4.2. One-third of men will not experience significant symptom reduction. the occurrence of adverse effects and lack of efficacy (8). As a result.5 Clinical efficacy The interpretation of existing literature regarding the efficacy of alpha-blocker therapy is clouded by the wide discrepancy in methodology and reporting of clinical studies. In general. Drop-outs occurred at the same rate. None of these trials continued therapy beyond the period of catheterization. 4.8 Acute urinary retention Early trials comparing alpha-blockers to placebo showed an increased likelihood of a successful trial. This is implied from in-vitro experiments and the predominant distribution of alpha1-receptors within the prostate and bladder neck. a large number of urologists have adopted this practice. secondary publications that have compared outcomes between these studies have been useful (5-7). compared with placebo (6). Long-term studies tend to be open-label extensions or increasingly ‘real life practice’ studies which do not conform to an experimental design.4. The effect seems to be independent of the type of alpha-blocker studied. 4. Djavan and Marberger’s meta-analysis estimated that overall symptoms improved by 30-40% and that flow rates improved by 16-25%.3 Pharmacokinetics Alpha-blockers are taken orally and the dosage depends on the half-life of the relevant drug. and one at terazosin (12). irrespective of whether symptoms were moderate or severe. the rate of sideeffects in studies looking at tamsulosin and alfuzosin were equivalent to placebo (4-10%). nasal congestion and retrograde ejaculation (6). Symptoms can improve within 48 hours.2. the exact contributions of alpha1-receptor subtypes and the potential central effects in vivo remain unclear.01 and 1. An I-PSS assessment requires at least one month of therapy.2. Studies have concentrated on two important reasons.2. asthenia. 36 UPDATE MARCH 2004 . dizziness.2. The rate of drop-out in men on alpha-blockers appears to be between 0. Tamsulosin. terazosin and doxazosin have the advantage of being long-acting. although flow rates do improve with these agents relative to placebo. in this context these types of design are informative. 4. Most men experience re-retention within the first two months (13).2.2. alfuzosin. Because of this. There is no evidence that efficacy diminishes with time. Whether this translates into a reduction in clinical side-effects remains to be seen. without catheter. Predicting response for any individual is more difficult and therefore a trial of therapy is required.2 Mechanism of action Alpha-blockers are thought to act by reducing the dynamic element of prostatic obstruction by antagonizing the adrenergic receptors responsible for smooth muscle tone within the prostate and bladder neck.2. Currently there is no method of predicting which men will show a response (4). Two trials have looked at alfuzosin (11). The various types of alpha-blockers cannot be distinguished by their ability to relieve symptoms or improve flow. the symptom status of men did not predict whether they were likely to stop therapy. The optimal duration of the trial of therapy has been debated. following an episode of acute urinary retention.2.6 Durability Good data on long-term efficacy and the effect on natural history are currently not available.2. However. postural hypotension.2. Urodynamic studies measuring voiding pressures do not reveal any significant relief of obstruction.2.2. Nevertheless.4 Assessment It is not unreasonable to offer a trial of alpha-blockers to all men with uncomplicated LUTS.
gov/entrez/query.gov/entrez/query.gov/entrez/query. Choa RG.2.nlm. alfuzosin. http://www. http://www. 2000.fcgi?cmd=Retrieve&db=PubMed&list_uids=1148621& dopt=Abstract 2.fcgi?cmd=Retrieve&db=PubMed&list_uids=10364649& dopt=Abstract 7.fcgi?cmd=Retrieve&db=PubMed&list_uids=9037281& dopt=Abstract 5. Witjes WP. double-blind extension of phase III trial.gov/entrez/query. Tamsulosin Investigator Group. Long-term quality of life in patients with benign prostatic hypertrophy: preliminary results of a cohort survey of 7093 patients treated with alpha-1 adrenergic blocker. Alpha blockers: are all created equal? Urology. Raz S.fcgi?cmd=Retrieve&db=PubMed&list_uids=9609624& dopt=Abstract 10.nlm.nih.ncbi. Urodynamic and clinical effects of terazosin in symptomatic patients with and without bladder outlet obstruction. 6.nih. • There is no difference between different alpha-blockers in terms of efficacy. Lepor H. Lukacs B. Proceedings of the Fourth International Consultation on BPH. Bladder outflow obstruction treated with phenoxybenzamine.fcgi?cmd=Retrieve&db=PubMed&list_uids=9732187& dopt=Abstract UPDATE MARCH 2004 37 . Review.4. A stratified analysis.fcgi?cmd=Retrieve&db=PubMed&list_uids=6184106& dopt=Abstract 4.nih. Debruyne FM.fcgi?cmd=Retrieve&db=PubMed&list_uids=11074198& dopt=Abstract 8.nih. Bono VA et al. Resel L.9 CONCLUSIONS • Alpha-blocker therapy can result in a rapid improvement in symptoms by a factor of 20-50% and an improvement in the flow rate of 20-30%.47:193-202.2.fcgi?cmd=Retrieve&db=PubMed&list_uids=88984& dopt=Abstract 3.gov/entrez/query.nlm.gov/entrez/query.10 REFERENCES 1.nlm. Chapple CR. eds. In: Denis L. July 1997. 1998. Grange JC. Marberger M. placebo-controlled studies.nih.gov/entrez/query. McCarthy C. Paris. Djavan B. Andersson KF. Caris CT.ncbi. Griffiths K.ncbi.nlm.gov/entrez/query.ncbi. These changes have been shown to be significant in randomized. Abrams PH. McCarthy C.nih. http://www. http://www. supportive data are weak. Eur Urol 1993. pp. Zeigler M.2. Debruyne FMJ. Khoury S et al. Caine M. Perlberg S.nlm. Br J Urol 1978. 4.50:551-554. A placebo controlled double blind study of the effect of phenoxybenzamine in benign prostatic obstruction.nih. Adrenergic and cholinergic receptors in the human prostate.ncbi. Although the side-effect profiles for some drugs are reported to be more favourable. treatment should be discontinued.fcgi?cmd=Retrieve&db=PubMed&list_uids=7687557& dopt=Abstract 9.nih. http://www. Sustained-release alfuzosin.ncbi.gov/entrez/query. http://www. • Patients should be informed about the side-effects of alpha-blocker therapy and the need for longterm use. Rosier PF.nlm. Long-term evaluation of tamsulosin in benign prostatic hyperplasia: placebo-controlled.51:901-906. http://www. Geffriaud-Ricouard C. Br J Urol 1975. Jardin A. Delauche-Cavallier MC.ncbi.2. de la Rosette JJMCH. Stone AR. Caine M. prostatic capsule and bladder neck.ncbi.56(5 Suppl 1):20-2. • Long-term data are limited but suggest that the benefits of treatment are sustained. Eur Urol 1999.54:527-530. Plymouth: Health Publications. Colloi D. Br J Urol 1982. Urology 1998.nih.49:197-205.ncbi. Urology 1997. finasteride and the combination of both in the treatment of benign prostatic hyperplasia. European ALFIN Study Group. 610-632.24(Suppl 1):34-40. Meretyk S. Debruyne FMJ. Eur Urol 1998.36:1-13.nlm. If a patient does not experience an improvement in symptoms after an 8-week trial. α-blockers clinical results. http://www. Shah PJ.34:169-175. QOL BPH Study Group in General Practice. Witjes WP. http://www.nlm. Meta-analysis on the efficacy and tolerability of alpha1-adrenoceptor antagonists in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction.
(3):CD001423. Hargreave TB. Hargreave TB.fcgi?cmd=Retrieve&db=PubMed&list_uids=10796790& dopt=Abstract Fagelman E. Da Silva FC. Daruwala PD.ncbi. 5. http://www.nih.nlm.nlm. Cochrane Database Syst Rev 2002. Urol 2000. Curr Opin Urol 2002. http://www.nih. Ishani A.gov/entrez/query. The role of phytotherapy in treating lower urinary tract symptoms and benign prostatic hyperplasia.163:307. Perrin P. The biological effects in unclear although a few randomized clinical trials show encouraging results. Lowe FC. 4. is also included to this chapter. transurethral incision of the prostate (TUIP) and open prostatectomy are the conventional surgical options.fcgi?cmd=Retrieve&db=PubMed&list_uids=12074791& dopt=Abstract Dreikorn K. McNeill SA. Mitchell I-DC.nlm.1:27. These agents are composed of various plant extracts and it is always difficult to identify which component has the major biological activity.77:Suppl. Mac Donald R.nih. Mitchel I-D. 4.ncbi. Mulrow C. Rutks I.ncbi. Wong WS. Two randomized controlled trials (RCTs) are available 38 UPDATE MARCH 2004 .3 Phytotherapeutic agents The use of phytotherapy in treating lower urinary tract symptoms and benign prostatic hyperplasia has been popular in Europe for many years and has recently spread in the USA. J.nih.11. Serenoa repens for benign prostatic hyperplasia. Urology 2001. Phytotherapy in the treatment of benign prostatic hyperplasia.6). Koch G. 58(Suppl 1):71-76.gov/entrez/query. Wilt T. Cochrane Database Syst Rev 2000.ncbi. an electrosurgical modification of the TURP-technique. Transurethral vaporisation. Vela-Navarrete R. A few short term randomized trials and some meta-analyses show clinical efficacy without major side effects for compounds such as Pygeum africanum and Serenoa repens (1-4). Shearer MG.nlm. Daruwala PD. Rizvi S.gov/entrez/query. McNeil SA. Urol Clin North Am 2002. Raynaud JP. 7.(1):CD001044.2 REFERENCES 1. Stark G.3 Surgical management Transurethral resection of the prostate (TURP). Lau J. 6. Mac Donald R.nih.84:622-627.2. 4. 12. Ishani A. Boyle P. Herbal medications in the treatment of benign prostatic hyperplasia (BPH). Hamdy FC.3.2. Can terazosin (alpha blocker) relieve acute urinary retention and obviate the need for an indwelling urethral catheter? Br J Urol 1996. Comparison of a phytotherapeutic agent (Permixon) with an alphablocker (Tamsulosin) in the treatment of benign prostatic hyperplasia: a 1-year randomized international study.41:497-506. Many questions concerning the composition. the extraction and the mechanism of action of these compounds still remain unanswered and therefore additional randomized. 13. Teillac P. Sustained-release alfuzosin and trial without catheter after acure urinary retention: a prospective placebo-controlled.fcgi?cmd=Retrieve&db=PubMed&list_uids=11869585& dopt=Abstract Wilt T. http://www.nlm.2. World J Urol 2002.29:23-239. http://www. Cheng CW.gov/entrez/query. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=12109350& dopt=Abstract Lowe FC. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=11750257& dopt=Abstract Debruyne F. 4. Eur Urol 2002.fcgi?cmd=Retrieve&db=PubMed&list_uids=12022711& dopt=Abstract 2. Chan LW.ncbi.gov/entrez/query. Gillenwater JG.ncbi. http://www.1 CONCLUSIONS The mode of action of phytotherapeutic agents is unknown. Stark G.nih. Fagelman E.nlm.gov/entrez/query. BJU Int 1999. Gallagher H. In some studies the efficacy of these compounds was found to be equivalent to finasteride and α-blockers (5. 3.nih. Long term follow-up following presentation with first episode of acute urinary retention.ncbi. Pygeum africanum for benign prostatic hyperplasia. http://www. http://www.gov/entrez/query.nih.19:426-435.fcgi?cmd=Retrieve&db=PubMed&list_uids=10510105& dopt=Abstract Chan PSF.gov/entrez/query.nlm.ncbi. Phytotherapy in the management of benign prostatic hyperplasia.12:15-18. placebo controlled trials are needed (7).nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=11753128& dopt=Abstract Lowe FC.3.
Post-void residual volume All four surgical procedures allow a reduction of the post-void residual volume of more than 50%: -65% after open prostatectomy. The UPDATE MARCH 2004 39 . A recent RCT has shown that Holmium-laser enucleation leads to similar outcome as open prostatectomy for men with large glands (> 100 mL) at a significantly lower complication rate (11).3. The highest Qmax improvement (+175%) is seen after open prostatectomy (absolute numbers: 8.3. TUVP is considered an alternative to TUIP and TURP. these methods are not described in more detail below. 4. serum Na+ < 130 nmol/L) is in the range of 2%. or if resection of bladder diverticula is indicated (8-10).5 Complications Intra-/peri-operative Mortality following prostatectomy has decreased significantly within the past two decades and is less than < 0. As RCT-data are not yet available.3.2 Choice of surgical treatment Ten RCT comparing TUIP to TURP are available (5-7). However.16). Risk factors for the development of the TUR-syndrome are excessive bleeding with opening of venous sinuses. the degree of bother and the presence of BPO (see above) (3. such as a lower incidence of complications. -60% after TUVP. Uroflowmetry The mean increase of Qmax following TURP is 115% (range: 80-150%) (6). Encouraging data are available for all these techniques.8-10).2-22. Increased post-void residual volume may also be used as an indication for surgery. and –55% after TUIP (4-11). prolonged operation time.3.for open prostatectomy. 4. associated complications such as large bladder stones. The RCTs comparing TURP to TUVP also revealed similar improvements of LUTS in both study arms (6). 4. The risk of a TUR-syndrome (fluid intoxication. with open prostatectomy leading to slightly superior results (4-11). Coagulating intermittent cutting. the Qmax increased by 155% (range: 128-182%) (6). rotoresection and bipolar electrocautery are electrosurgical modifications of the conventional technique (12-14). Following TUVP. large glands and past or present smoking (20). there is a great intra-individual variability and an upper limit requiring intervention has not been requiring intervention has not been defined.3. They showed similar improvements of LUTS in patients with small prostates (< 20-30 mL) and no middle lobe (5-7). Open prostatectomy is the treatment of choice for large glands (> 80-100 mL).25% in contemporary series (6.1 Indications for surgery The most frequent indication for surgical management is bothersome LUTS refractory to medical management (1. TUIP.3 Perioperative antibiotics A known urinary tract infection should be treated before surgery (15. while TURP. Intra. TUIP has several advantages has several advantages over TURP. in absolute terms + 9. 4. -60% after TURP. the data of large scale RCT are awaited with interest (12-14).4 Treatment outcome LUTS All four surgical procedures (TURP.2). TUVP and open prostatectomy) result in an improvement of LUTS exceeding 70%. TUIP and TUVP have been subjected to a number of RCTs. Variables that most likely predict the outcome of prostatectomy are severity of LUTS. decreased risk of retrograde ejaculation and shorter operating time and hospital stay. yet a higher long-term failure rate.6 mL/s) (6). However.6 mL/s) (6. In the 10 RCTs comparing TURP to TUIP. TURP comprises 95% of all surgical procedures and is the treatment of choice for prostates sized 30-80mL. both procedures resulted in a similar improvement in symptoms after 12 months (5-7). Mean improvement of LUTS in a meta-analysis of 29 RCT with a TURP-arm was 71% (range: 66-76%) (6). 4. minimal risk of bleeding and blood transfusion. particularly for patients with bleeding disorders and small prostates.and postoperative complications are correlated with the size of the prostate and the length of the procedure. antibiotics are recommended in patients on catheterisation prior to surgery.17-19). The following complications of BPH/BPE are considered strong indications for surgery: • refractory urinary retention • recurrent urinary retention • recurrent haematuria refractory to medical treatment with 5-alpha reductase inhibitors • renal insufficiency • bladder stones.4).7 mL/s (range: 4-11. The routine use of prophylactic antibiotics remains controversial.
Kane CJ.7 CONCLUSIONS AND RECOMMENDATIONS Surgery should be considered for those men: • who are moderately/severely bothered by LUTS. National Prostatectomy Audit Steering Group. Emberton M. In addition: • Surgical prostatectomy (open.157:1304-1308. The only RCT that compared TURP to a “wait and see” policy reported identical rates of erectile dysfunction in both arms (4). The frequently reported rise of erectile dysfunction after TURP is therefore most likely not a direct consequence of TURP but rather caused by confounding factors.5% (95% Cl: 0. TUVP) results in significant subjective and objective improvements superior to medical or minimally invasive treatment. Br J Urol 1998. on erectile function. 4. All four surgical procedures have been evaluated in randomised controlled trials.3. 65-70% after TURP and 40% after TUIP (4-11).gov/entrez/query. Sexual function: Retrograde ejaculation results from the destruction of the bladder neck and is reported in 80% after open prostatectomy. such as age.19.8 1.8% after open surgery. TURP. • TUIP is the surgical therapy of choice for men with prostates < 30 mL and no middle lobes. http://www.162:1307-1310. Neal DE.nlm.3. Testing to predict outcome after transurethral resection of the prostate.fcgi?cmd=Retrieve&db=PubMed&list_uids=9120927& dopt=Abstract 2. Bladder neck contracture and urethral stricture: The risk of developing an urethral stricture is 2.8% following TUIP. Long-term risk of mortality The possibility of an increased long-term risk of mortality after TURP compared to open surgery has been raised by Roos et al. Phelan M. A secondary prostatic operation is reported at a constant rate of approximately 1-2% per year (4-11). 2. particularly TURP. The respective figures for TUVP are in the range of TURP (6).81:712-720. 4% after TURP and 0. one RCT reported an incontinence rate of 5% (6. Immediate and postoperative complications of transurethral prostatectomy in the 1990s.nih. who not want medical treatment but who request active intervention. • with bothersome LUTS.nih.nlm. 4.nih. http://www. 40 UPDATE MARCH 2004 .6% after open prostatectomy.2% following TURP. In the 29 RCTs recently reviewed. 4. The risk of bladder neck contracture is 1. Reda DJ.nlm.3. There is a long-standing controversy on the impact of prostatectomy. Sands JP. The risk of bleeding following TUIP and TUVP is negligible (6). J Urol 1997. Higher percentages have been reported following open prostatectomy (6.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9634047& dopt=Abstract Bruskewitz RC.22).7%) (6).ncbi.6 Long-term outcome Retreatment rate Favourable long-term outcome is common after open prostatectomy.ncbi. • with a strong indication for surgery.4% after TUIP (4-11). yet who do not improve after non-surgical (including medical) treatment.gov/entrez/query. The management of men with acute urinary retention. Ward JF. http://www. J Urol 1999. (18). Few data are available on the long-term outcome following TUVP. 3.ncbi.21).estimated need for blood transfusion following TURP is in the range of 2-5%. and up to 10% following open prostatectomy (4-11). Barrett L. Wasson JH. TUIP. 3. These findings have not been replicated by others (17.2-12.7% after TUIP (4-11).fcgi?cmd=Retrieve&db=PubMed&list_uids=10492185& dopt=Abstract Pickard R.8% after TURP and 1.8-10). the incidence of erectile dysfunction following TURP was 6. Long-term complications Incontinence: Median probability for developing stress incontinence ranges is 1. REFERENCES Borboroglu PG. Roberts JL. Limited information on this issue is available for TUVP. TURP and TUIP.
BJU Int 2002. Keller AM. Urology 2002.nih.nih.gov/entrez/query. 6.nih. http://www.gov/entrez/query. http://www. Francis RN.ncbi. Lehrich K. Vicentini C.fcgi?cmd=Retrieve&db=PubMed&list_uids=10233485& dopt=Abstract Tkocz M.gov/entrez/query. http://www.ncbi. J Urol 2002. Kohrmann KU.fcgi?cmd=Retrieve&db=PubMed&list_uids=11857663& dopt=Abstract Tubaro A.165:1526-1532.gov/entrez/query.91:65-68.ncbi. New Engl J Med 1995.ncbi. in patients with benign prostatic hypertrophy. Br J Urol 1998.ncbi. Reda DJ. Single-dose antibiotic prophylaxis in transurethral resection of the prostate: a prospective randomized trial.nlm. Marzi M. Rotoresect for bloodless transurethral resection of the prostate: a 4-year follow-up.fcgi?cmd=Retrieve&db=PubMed&list_uids=12385922& dopt=Abstract Kuntz RM. Harmuth H. J Urol 2001. Motta M. Peters TJ.nih.gov/entrez/query.nih.168:1465-1469. Elinson J. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia.81:827-829.37:199-204. http://www. 11. Gahli AM.ncbi. 15.fcgi?cmd=Retrieve&db=PubMed&list_uids=9666765& dopt=Abstract UPDATE MARCH 2004 41 .ncbi. Is transurethral resection of the prostate still justified? Br J Urol 1999.39:676-681.nlm. Coagulating intermittent cutting. Miano L.nlm.nih. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. Morgia G.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=10705199& dopt=Abstract Scholz M. Hind A. Eur Urol 2001. 14. Mearini L.nlm. Pavone-Macaluso M for the members of the Sicilian-Calabrian Society of Urology. Bruskewitz RC.ncbi. Eur Urol 1998. Carter S. http://www. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions.nih.gov/entrez/query. Fastenmeier K. J Urol 2001.nih.nlm.gov/entrez/query. The provision of transurethral prostatectomy on a day-case basis using bipolar kinetic technology. 16. 8. http://www. 7.34:480-485. Wasson JH. Prajsner A. LoBianco A. Saad MS. 10.nlm. http://www.nlm. Knoll T. Risk factors in prostatectomy bleeding: preoperative urinary tract infection is the only reversible factor.fcgi?cmd=Retrieve&db=PubMed&list_uids=7527493& dopt=Abstract Yang Q. Zucchi A. A prospective study of the safety and efficacy of suprapubic transvesical prostatectomy in patients with benign prostatic hyperplasia. http://www. Holtl W.nih.ncbi. Marberger M.gov/entrez/query.nlm.nlm.ncbi.gov/entrez/query. Eur Urol 2000.nih.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11942959& dopt=Abstract Elmalik EM.166:172-176. 9. BJU Int 2003. http://www. Fondacaro L.89:534-537.nlm. Transurethral incision compared with transurethral resection of the prostate for bladder outlet obstruction: a systematic review and meta-analysis of randomised controlled trials.83:227-237. Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate.nlm. Melloni D.nih. Pirritano D.ncbi.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=11464057& dopt=Abstract Michel MS. http://www. Bahar YM.fcgi?cmd=Retrieve&db=PubMed&list_uids=11342911& dopt=Abstract Madersbacher S. Improved highfrequency surgery in transurethral prostatectomy. Luftenegger W. http://www. Leyh H. http://www. Orestano F. Henderson WG.fcgi?cmd=Retrieve&db=PubMed&list_uids=12352419& dopt=Abstract Hartung R.nih. 12.nlm.4. Neurourol Urody 2002.gov/entrez/query. 13. Porena M.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12614253& dopt=Abstract Eaton AC. Wolf D. Abrams P. Ibrahim AI.60:623-627. 5. Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100grm: a randomised prospective trial of 120 patients.fcgi?cmd=Retrieve&db=PubMed&list_uids=11435849& dopt=Abstract Mearini E.21:112-116.gov/entrez/query. Barba M. Liapi C. http://www. Curto G. Donovan JL. Wilt TJ.332:75-79.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9831789& dopt=Abstract Serretta V. Alken P. Trojan L. Open prostatectomy in benign prostatic hyperplasia: 10-year experience in Italy.
side-firing Nd:YAG laser instrument (the TULIPTM device) for BPH therapy appeared in the urological literature (7. Bass AJ. Breda G. 19.4. flexible. Francesca F.8).gov/entrez/query. Ramsey E. Holman CD. the TULIPTM device was abandoned and other authors experimented with even greater prostatic tissue ablation using a much simpler side-firing Nd:YAG laser delivery system.fcgi?cmd=Retrieve&db=PubMed&list_uids=9612677& dopt=Abstract Shalev M. J Urol 1999.2).gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10688086& dopt=Abstract Hahn RG. http://www.2 Right-angle fibres From 1991 onward.ncbi.nih. Rouse IL. Comeri G. Malenka DJ. Hammar N. as far as durability is concerned. (3) reported the use of the Nd:YAG laser to perform prostatectomy in 10 patients with BPH. Wisniewski ZS. The use of contact lasers using a bare fibre has been abandoned. Muto G. Holmium:YAG. Boccafoschi C.5). The difference between coagulation and vaporization is that coagulation causes little vaporization and depends on temperature changes to achieve permanent tissue damage.1 Laser types Four types of laser have been used to treat the prostate: Nd:YAG.nih. Incidence of acute myocardial infarction and cause-specific mortality after transurethral treatments of prostatic hypertrophy. Long-term incidence of acute myocardial infarction after open and transurethral resection of the prostate for benign prostatic hyperplasia.ncbi. http://www. Perachino M. Urology 2000.nlm.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=11435847& dopt=Abstract Gallucci M. Operative technique Side-firing laser prostatectomy is performed using Nd:YAG laser light at 1064 nm and relatively high power settings (typically between 40 and 80 W). Mandressi A. 4. Andersen TF.nih. Interstitial treatments depend on inserting the fibre into the prostatic tissue and the use of coagulation techniques (6). http://www. 21.nlm. Puppo P. long-term follow-up results are only available from initial studies. In subsequent years. Nissenkorn I.17.nlm. KTP:YAG and diode.33:359-364. This effect decreases forward scatter into tissue and may cause less tissue oedema.gov/entrez/query.ncbi.nih. Resection of a multicentric.4 Lasers The use of lasers to treat BPH has been contemplated since 1986 but was anecdotal until the early 1990s (1.nih. and other. Transurethral electrovaporization of the prostate vs. BJU Int 1999. when Shanberg et al.gov/entrez/query. which is associated with tissue oedema.nlm. resulting in marked improvement in their voiding symptoms. right-angle fibre or interstitial fibre.161:491-493. There is also secondary tissue slough. 22. Energy can be delivered through a bare fibre. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. These.nlm. transurethral resection. This fibre fits through standard cystoscopes and all laser applications are performed 42 UPDATE MARCH 2004 .ncbi.ncbi. McPherson K. http://www. With the development of the right-angle fibre and the refinement of both equipment and technique. randomised clinical study on 150 patients. Fisher ES. Guazzieri S. Shpitz B. delivered via an optical fibre equipped with a distal reflecting mechanism. N Engl J Med 1989. Pappagallo GL. 4. the results of many studies have been published.nlm. Persson PG. Hallin A. http://www.166:162-165. Eur Urol 1998. energy levels can be varied to achieve coagulation or vaporization.fcgi?cmd=Retrieve&db=PubMed&list_uids=2469015& dopt=Abstract Hahn RG. Kessler O. In addition.598 men after surgery for benign prostatic hyperplasia. which cause the tissue to be dehydrated (4. Smoking increases the risk of large scale fluid absorption during transurethral prostatic resection. Richter S.55:236-240. Fredman B.4. Farahmand BY. J Urol 2001. Semmens JB. Vaporization depends upon temperature changes of over 100oC.84:37-42. reports documented the fact that prostatic tissue ablation could be achieved using the Nd:YAG laser. This consisted of a gold-plated mirror affixed to the distal end of a standard. Mortality and prostate cancer risk in 19.gov/entrez/query. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=10444122& dopt=Abstract Roos NP. Cohen MM. reports describing a TRUS-guided. Wennberg JE. laser transmission fibre (UrolaseTM fibre) (9). 18. silica-glass. 20.320:1120-1124.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9915433& dopt=Abstract 4. However. Fortunato P.ncbi.
1% of TURP patients.seem comparable to documented reoperation rates after TURP (18).19-21). The operating time is approximately 45 minutes or less. No study has reported any occurrence of impotence or sustained incontinence. prospective evaluation. The major limitation of the laser technique compared with conventional TURP is the lack of immediate effect and requirement for urinary catheter drainage for several post-operative days.3 ILC ILC as a therapy for BPH was first mentioned by Hofstetter in 1991 (25). All patients had undergone pressure-flow studies at 3 months after laser treatment: 32 previously obstructed patients were unobstructed. (10). durability and limitations There have been many studies comparing side-fire laser to TURP. As far as complex urodynamic evaluation is concerned. In fact. and the Diffusor-TipTM. Both the US and UK multicentre trials documented dramatic differences in serious treatment-related complications. The operation may be performed under general or regional anaesthesia. Costello et al. The objective of ILC of BPH is to achieve marked volume reduction and to decrease urethral obstruction and symptoms. As the applicator can be inserted as deeply and as often as necessary. sparing its urethral surface. The best results are obtained if the weight of the gland is below 50-60 g. Kabalin et al. 4. Results of pressure-flow studies have been reported by several authors (8. men with chronic urinary tract infections and chronic bacterial prostatitis are not good candidates for Nd:YAG laser coagulation of the prostate (18) because of the possibility of infection of the necrotic tissue that remains in situ for several weeks after the operation.transurethrally under the direct visual control of the surgeon.12. (14) found equivalent voiding outcomes for the two procedures. an improvement in voiding occurs only gradually. these techniques. The most commonly used fibres are ITT Light GuideTM.or 6-months of post-operative follow-up.22). Operative technique Fibres employed for ILC must emit laser radiation at a relatively low power density. in larger glands significant amounts of obstructive prostatic tissue can be left behind (17). (18) reported that 85% of men undergoing laser prostatectomy could expect at least a 50% improvement in either prostate symptom score or peak urinary flow rate. the intraprostatic lesions result in secondary atrophy and regression of the prostate lobes rather than sloughing of necrotic tissue (27). showing an equivalent improvement in symptom scores and increases in uroflow rates in both groups. The UPDATE MARCH 2004 43 . Further long-term follow-up studies are needed. Outcome. After 5 years. with local. serious treatment-related complications occurred in 11. randomized.approximately 2% per year of followup . Moreover. several variations and technical and procedural developments have been introduced and tested in clinical trials (26). These data therefore suggest caution in giving indications to laser treatment. In a single-institution. Since then.8% of laser prostatectomy patients and 35. These authors reported that 78. and most patients do not notice significant benefits until approximately 3-4 weeks post-operatively. Indigo. Optimal tissue ablation is achieved using long-duration (60-90 seconds) Nd:YAG laser applications to fixed spots along the prostatic urethra. With regard to durability. During the 3-year post-operative follow-up. the observed retreatment rates following laser prostatectomy . Coagulation necrosis is generated within the adenoma. If randomized studies are considered.8% of these patients underwent TURP because of recurring obstruction.6-95% of men undergoing laser treatment were rendered unobstructed at 3. Even after catheter removal. Retrograde ejaculation has been reported in up to 22% of patients. 43. Disadvantages are the delayed time to normal voiding and severe dysuria (8. Nd:YAG lasers or diode lasers are used for ILC. TURP and TUIP.13). several studies have demonstrated the ability of side-firing laser prostatectomy to produce a significant improvement in bladder outflow obstruction. it is possible to coagulate any amount of tissue at any desired location. Such a retreatment rate is definitely greater than that observed after TURP and even after TUIP. An improvement in voiding produced by side-firing Nd:YAG laser prostatectomy has been extensively documented in the urological literature. morbidity. an Italian retrospective study of 36 patients submitted to side-fire Nd:YAG laser prostatectomy with a minimum follow-up of 5 years reported striking results (23). favouring laser prostatectomy as a much safer procedure than TURP (12. These laser applications are repeated systematically and with considerable overlap until all visible obstructing prostatic tissue has been coagulated (11). Dornier. Catheter irrigation is generally not required and blood loss is statistically lower with Nd:YAG laser coagulation than with TURP because of the excellent haemostasis produced.4. although they are higher in the TURP arms (12-17). particularly in patients who are candidates for TURP or TUIP. Conversely. but again documented differences in morbidity between these operations. regional or systemic anaesthesia. offer better long-term results and comparable (if not superior) efficacy than laser prostatectomy. Some patients may require catheterization for 3-4 weeks or more (24). ILC can be carried out using the transurethral approach. Post-procedure. emergent TURP has been reported to solve this problem (8). the results are quite similar. or under local peri-prostatic block as described by Leach et al.
The retreatment rate is up to 15. In 394 patients followed for up to 3 years.3%) were considered to be treatment failures and underwent TURP. durability and limitations Studies were performed to compare the results with ILC with those of other laser techniques. only a few studies with a short follow-up have been published to date. p < 0. 4. p < 0. The Ho:YAG wavelength is strongly absorbed by water and the zone of coagulation necrosis in tissue is limited to 3-4 mm. the longest available follow-up is only 12 months. Outcome. so far. 120 patients with urodynamic obstruction have been enrolled with prostates less than 100 g in size (Schafer grade 2).35).0001). with an incidence ranging from 0-11. which has confirmed the shortterm durability of the procedure (36).4 Holmium laser resection of the prostate (HoLRP) The Holmium laser (2140 nm) is a pulsed.0 vs.laser fibre is introduced from a cystoscope within the urethra. Post-operative irritative symptoms have been observed in 5-15% of patients (28. such as the need for longer post-operative catheterization and the lack of tissue for biopsy.4 hours.38). residual urine volume and prostate volume (26-31).1 vs. one or two placements are used for each estimated 5-10 cm3 of prostate volume. such as almost no serious morbidity. As for morbidity. The results of several studies indicated the effectiveness of ILC in treating BPH with regard to symptoms.0001) and length of hospital stay (26. the retreatment rate is expected to be higher.0001) for HoLRP patients.4. Post-operative catheterization was required for an average of up to 18 days.9%. As a general guideline. peak flow rate. and have been reported in approximately 5% of patients. The basic principle of the technique consists of retrograde enucleation of the prostate and fragmentation of the enucleated tissue to allow its elimination through the operating channel of the resectoscope (38. the sites for fibre placement are chosen according to where the bulk of hyperplastic tissue is found (26). further comparative randomized studies with longer follow-up are needed to assess the durability of this procedure. Preliminary analysis has revealed a longer mean resection time (42. 37.39). reported on a series of 97 patients with severely symptomatic BPH. Within 12 months. the results of only one long-term follow-up study are available (36). Urethral strictures or bladder neck strictures are not common. In general. but a shorter mean catheter time (20. 47. such as urgency (25). and certain disadvantages.1% per year in the first year. Urodynamic parameters were also measured before and after ILC treatment (32. Currently.4 vs. All studies reported marked improvements in symptom score. Pressure-flow studies demonstrated a sufficient decrease of the intravesical pressure. p < 0. Prostatectomy using this energy source is a relatively new technique with the first patient reports appearing in 1995 (37. The peak power achieved results in intense tissue vaporization and in precise and efficient cutting ability in the prostatic tissue.34). four ILC patients (8. solid-state laser that has been used in urology for a variety of endourological applications in soft tissues and for the disintegration of urinary calculi (37). However. although as follow-up becomes longer. durability and limitations As this technique is relatively new. morbidity. normal saline is used as the irrigant. the retreatment rate was 3. urethral opening pressure and urethral resistance. sufficient to obtain adequate haemostasis (38).34. clearly demonstrating that HoLRP is associated with significantly shorter catheter time and a lower incidence of post-operative dysuria (41).4% with a maximum follow-up of 12 months. The total number of fibre placements is dictated by the total prostate volume and configuration. (40) presented the results of a prospective. Unfortunately. Comparative studies of Nd:YAG versus prostatectomy have been conducted. Symptomatic and urodynamic improvement were equivalent in the two groups. randomized trial comparing TURP with HoLRP. 48 patients received ILC and 49 underwent TURP (34). However. obstruction and enlargement. Muschter et al. there is a temporary increase of obstruction after ILC. though retrograde ejaculation was occasionally reported.8 minutes. Gilling et al. which can result in urinary retention and temporary irritative symptoms. although the catheter was removed within 10 days in more than 70% of cases. rising to 9. Operative technique Instrumentation for this technique includes a 550-µm end-firing quartz fibre and an 80-W Ho:YAG laser. No study has reported any occurrence of impotence or sustained incontinence. morbidity. there were no statistical differences between groups for all the considered parameters.31. primarily TURP.2 hours. A continuous flow resectoscope is required with a working element. 25. Outcome. Prospective and randomized studies were also performed to compare the results achieved with ILC with those of other laser techniques (33) and TURP (30. ILC can be performed in small prostates and also seems to be suitable to debulk larger prostates or to treat highly obstructed patients (26). 44 UPDATE MARCH 2004 .33).6% thereafter (36). This procedure can be seen as a true alternative to TURP in selected patients with some advantages.
http://www.147:346A. Kabalin JN. however.fcgi?cmd=Retrieve&db=PubMed&list_uids=7985315& dopt=Abstract Cowles RS 3rd.46:155-160.fcgi?cmd=Retrieve&db=PubMed&list_uids=7544932& dopt=Abstract 2. Ganabathi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7509525& dopt=Abstract Muschter R. In: Smith JA et al. Cromeens DM. A prospective randomized comparison of transurethral resection to visual laser ablation of the prostate for the treatment of benign prostatic hyperplasia. there are no specific limitations to the procedure. randomized.ncbi. REFERENCES Kandel LB.46:305-310.133:110A. http://www. 7. Ricciotti G.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542818& dopt=Abstract Anson K.gov/entrez/query.4.fcgi?cmd=Retrieve&db=PubMed&list_uids=1379101& dopt=Abstract Leach GE. UPDATE MARCH 2004 45 . no post-operative impotence has been reported (38). Childs S.nlm. Johnson DE.6 1.nih.5:145-149. Other lasing techniques. although the presence of a prostate gland over 100 mL is a relative contraindication in urologists' early experience (38). Patients on anticoagulant medication and those with urinary retention can be safely treated (43). Dixon C. The optimisation of laser prostatectomy. Lasers in Urologic Surgery.ncbi.40. Nawrocki J. Urology 1995. Assimos DG. Hofstetter A. Shanberg AM. Kirby R. Paterson P. Interstitial laser prostatectomy . Bolton DM. Conversely.ncbi. No major complication has been described. the technique is a surgical procedure that requires significant endoscopic skill and cannot be considered easy to learn. Laser ablation of the prostate in patients with benign prostatic hypertrophy. 10. Dmochowski R. Sirls L. SPIE Proceedings 1991. Perachino M. Tansey LA. 12.gov/entrez/query. Transurethral laser prostatectomy: Creation of a technique for using the Neodymium-Yttrium. 10. Muschter R.nlm. Eur Urol 1994. Watson G.nih. Price RE. The use of the neodymium YAG laser in prostatotomy. Fowler C.ncbi.5 CONCLUSIONS Laser prostatectomy should be advised for patients who are: • receiving anticoagulant medication • unfit for TURP (side-fire or ILC) • wanting to maintain ejaculation (side-fire or ILC) • holmium laser prostatectomy is a viable alternative to TURP and irrespective of any anatomical configuration.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=7515349& dopt=Abstract Costello AJ. http://www.25:220-225. McCullough DL. USA: Mosby. J Endourol 1991.4.experimental and first clinical results.69:603-608.nlm. Stein B. 13.42). Urology 1994. Levinson AK.gov/entrez/query. J Urol 1986.44:856–861.nlm.gov/entrez/query.nlm. Urology 1995. McCullough DL. 9. 6.nih. the size of the prostate that can be treated depends on the experience and patience of the urologist. Hessel S. 1994. Urology 1994. Pathologic changes occurring in the prostate following transurethral laser prostatectomy. 4. Braslis KG. Zabbo A. prospective study of endoscopic laser ablation versus transurethral resection of the prostate. Lepor H. Transurethral laser prostatectomy using a right-angle delivery system. 3.gov/entrez/query. Lawrence W. with an incidence of approximately 10% (38. Greskovich FJ. 5. St Louis.nlm. Lasers Surg Med 1992.Post-operative dysuria is the most common complication. II. J Urol 1992. eds. 8. Roskamp D. Woodruff RD et al. Harrison LH.133:331A. Baghdassarian R.nih.1421:36.12:254-263.gov/entrez/query. Laser-tissue interaction.Aluminium-Garnet (YAG) laser in the canine model. Transurethral ultrasound-guided laser-induced prostatectomy: objective and subjective assessment of its efficacy for treating benign prostatic hyperplasia. Perlmutter AP. 4. Br J Urol 1992.ncbi. Stein BS. A multicenter. http://www. Scannapieco G. http://www. p. Outpatient visual laser-assisted prostatectomy under local anesthesia. J Urol 1985. Puppo P. 4. Bowsher WG. http://www. Burt J. Canine transurethral laser-induced prostatectomy. 11.43:149-153.ncbi. Buckley J.nih. Johnson DE. Retrograde ejaculation occurs in 75-80% of patients.
com/ Perachino M. Doll S. TURP: modification of laser prostatectomy technique with biodegradable stent insertion.nih.gov/entrez/query. Proceedings of the Fourth International Consultation on BPH.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933808& dopt=Abstract Muschter R.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933807& dopt=Abstract Kabalin JN. J Urol 1996.10 (Suppl 1):S191. Oswald M. De Wildt MJ. http://www. J Urol 1996.nih. J Endourol 1997.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8535680& dopt=Abstract Cannon A. http://www. http://www. Crowe HR. Abrams PH.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334638& dopt=Abstract Hofstetter A. Initial results of a randomized trial comparing interstitial laser coagulation therapy to transurethral resection of the prostate.] Acta Urol Ital 1998. Br J Urol 1995. Laser prostatectomy performed with right angle firing neodymium: YAG laser fiber at 40 watt power settings.fcgi?cmd=Retrieve&db=PubMed&list_uids=8886064& dopt=Abstract Stein BS. Neodymium:YAG laser coagulation prostatectomy: 3 years of experience with 227 patients. Chan SL. Puppo P.12(Suppl 1):44. J. Griffiths K. Debruyne FM.gov/entrez/query.155:310A.gov/entrez/query. Wijkstra H. Hofstetter A. J Urol 1997. Bruschter R et al. Kabalin JN. Muschter R.nlm.nih. 46 UPDATE MARCH 2004 . A new technique of subsurface and interstitial laser therapy using a diode laser (wavelength = 1000 nm) and a catheter delivery device. Neodymium: YAG laser coagulation prostatectomy for patients in urinary retention. eds.nlm. http://www.gov/entrez/query. Perlmutter A. Bite G.13:109-114.nih. 25. Whitfield HN. Schettini M. In: Denis L. http://www. [Prostatectomia laser con metodica side-fire: risultati a distanza di 5 anni. Urodynamic assessment in the laser treatment of benign prostatic enlargement. J Urol 1996. Plymouth: Health Publications.ncbi. 1998.76:604-610.ncbi.gov/entrez/query. Whitfield H. Diana M. 20.gov/entrez/query.nlm. Endourol 1996.nlm. Paris. De la Rosette JJ.ncbi.nih. Urology (letter) 1997. Technique and results of interstitial laser coagulation.ncbi.157:42A. Khoury S et al. Lasermedizin 1991.plymbridge.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542968& dopt=Abstract Choe JM.35:147-154. Combination of thermocoagulation and vaporisation using a Nd:YAG/KTP laser versus TURP in BPH treatment: preliminary results of a multicenter prospective randomized study.nlm. Eur Urol 1999. Altwein JE. 15. pp. Long-terms results of randomized laser prostatectomy vs.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490827& dopt=Abstract Te Slaa E.157(Suppl 1):41. 16.nih.nlm. Jichilinski P et al. High-energy visual laser ablation of the prostate in men with urinary retention: pressure flow analysis. Sirls LT.ncbi.nih.gov/entrez/query. Kahn R et al. J Urol 1996.155:181-185. A randomized prospective multicenter study evaluating the efficacy of interstitial laser coagulation. [Italian] Kabalin JN.nih. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=9181452& dopt=Abstract Costello AJ. World J Urol 1995. Urodynamics and laser prostatectomy. J Urol 1997.nlm. 29. de la Rosette JJ. Results of interstitial laser coagulation of the prostate.ncbi. http://www. Rosier PF. 31.14. Laser prostatectomy. Interstitielle Thermokoagulation (ITK) von Prostatatumoren. Kabalin JN. 30.ncbi.nlm. 23. 22. Bite G. http://www. 28. 26.ncbi. 21.ncbi. http://www. Fay R.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542962& dopt=Abstract Bhatta KM.7:179-180.35:138-146. 24.gov/entrez/query. Costello AJ.158:1923.nlm.155:318A. 19. http://www. Asopa R. 18. World J Urol 1995. Eur Urol 1999. 27. Cho G et al.11:207-209.nih. Schmidlin F. July 1997. 529-540. De Wildt M. 17.155:316A.13:134-136. Urology 1996. Side-firing neodymium:YAG laser prostatectomy.48:584-588. Interstitial laser therapy of benign prostatic hyperplasia. Fortunato P et al.
nih. Fraundorfer MR.nlm. 36. Combination Holmium and Nd: YAG laser ablation of the prostate: initial clinical experience. Cass CB. J Endourol 1997.32. prospective study.nlm. Transurethral and transperineal interstitial laser therapy of BPH. Strasser H. 33. Teillac P. Laser-induced Interstitial Thermotherapy. J Urol 1997.nih. Urology 1998.spie. Holmium: YAG laser resection of the prostate (HoLRP) versus transurethral electrocautery resection of the prostate (TURP): a prospective randomized.nih. Perlmutter AP et al. the following parameters should be obtained: • I-PSS. In: Muller G et al. Denstedt JD. Fraundorfer MR. pp.nih. J Endourol 1995.ncbi. Razvi HA. Cass CB. A randomized. 41. eds.9(Suppl 1):S149. The Holmium YAG laser in the transurethral resection of prostate. Gilling PJ. Greschner M.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933809& dopt=Abstract Gilling PJ.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=9118394& dopt=Abstract Gilling PJ. Are contact laser. Thermocoagulation au laser de l’adenome de la prostate par voie interstitielle. Alken P. the predominant UPDATE MARCH 2004 47 .10(Suppl 1):S197.nih. Reissigl A. If the site-intensity is set below the tissue cavitation threshold. Holmium laser resection of the prostate (HoLRP) versus neodymium: YAG visual laser ablation of the prostate (VLAP): a randomized prospective comparison of two techniques for laser prostatectomy. 42.80(Suppl 2):A773. Malcolm A. J Endourol 1996. Holmium laser resection of the prostate. Br J Urol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=9376851& dopt=Abstract 4. 39.2 Procedure A beam of ultrasound can be brought to a tight focus at a selected depth within the body. Laser prostatectomy with the holmium:YAG laser.gov/entrez/query.11:291-293. http://www. J Endourol 1995.gov/entrez/query. Janetschek G.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9157819& dopt=Abstract Le Duc A. Eur Urol 1999. Mackey MJ.157:149A.5.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7633476& dopt=Abstract Chun SS.nih.ncbi. 1995. http://www.gov/entrez/query.nlm. The use of an interstitial diode laser (Indigo) in laser prostatectomy. Cresswell MD. Ann Urol (Paris) 1997.ncbi.31:255-263. 43.1 Assessment No specific diagnostic work-up prior to transrectal HIFU therapy is necessary. 40. including quality of life • Free uroflowmetry. Fraundorfer MR. Desgrandchamps F. including post-void residual urine volume • Serum PSA • TRUS • Pressure-flow study advisable. Tech Urol 1995. 38. Malcolm AR. 34. 4.ncbi. urodynamicbased clinical trial. http://www.nih. 37. 51: 573-577. controlled. Cresswell M. Hofstetter A. Anidjar M.nlm.ncbi.31:27-37. http://www.1:217-221.35:155-160. and transurethral ultrasound-guided laser-induced prostatectomy superior to transurethral prostatectomy? Prostate 1997. Whitfield HN. Henkel TO.9:151-153.org/index. Gilling PJ. Bellingham: SPIE Press.cfm?fuseaction=SearchResultsVolume&keywords=Laser-induced%20 Interstitial%20&searchtype=SearchResultsVolume&quicksearch=1&CFID=353971&CFTOKEN=68929120 Horninger W. 35. Sroka R.5 Transrectal high-intensity focused ultrasound (HIFU) 4. High power interstitial laser coagulation of benign prostatic hyperplasia. Fraundorfer MR. Watson G.gov/entrez/query. http://bookstore. Kabalin JN. interstitial laser. http://www.gov/entrez/query. Kabalin JN. thus producing a region of high energy density within which tissue can be destroyed without damage to the overlying or intervening structures (1-3). de la Rosette JJ. Bartsch G.ncbi. However.fcgi?cmd=Retrieve&db=PubMed&list_uids=9180936& dopt=Abstract Muschter R. http://www. Gilling PJ. Luppold T. Muschter R.gov/entrez/query. http://www. 416-423.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9586609& dopt=Abstract Le Duc A.5. Kabalin JB. Holmium: YAG laser resection of the prostate (HoLRP) for patients in urinary retention.
perforation of the descending colon approximately 50-60 cm above the treatment zone occurred. This system uses the same 4. No cases of urethral strictures.3 mL/s to 14. In one patient. The AUA symptom score reduced from 24.6) mL/s (6 months.5. the post-void residual urine volume decreased from 131 (± 120) mL to 48 (± 41) mL at 6 months and to 35 (± 30) mL at 12 months.5) mL/s (12 months. Thirty patients underwent urodynamic investigations (pressure-flow study) before and after a mean of 4. In the same time period. Bihrle et al. (12). 4.260 to 2. (8) treated 35 patients. The second severe complication was a thermolesion of the rectum requiring surgical intervention. 20 of whom were followed up for 12 months (5). The Qmax increased from 9.1 (± 6.7) to 13. In order to create a clinically useful volume of necrosis.5.5.5 months following HIFU therapy. The most prominent side-effect is prolonged urinary retention. To date.9 to 7. only transrectal HIFU devices are applied for the indication of BPH. Haematospermia for 4-6 weeks is observed in up to 80% of sexually active men.4 (± 4.1) to 12. transrectal HIFU is well-tolerated but requires general anaesthesia or heavy intravenous sedation. although some patients report a decreased ejaculate volume. Within the HIFU beam focus. In clinical use. The initial report of the study included 50 patients. there is little data on sexual function. Retrograde ejaculation and erectile dysfunction can be safely avoided. Two severe complications have been reported. (13). the post-void residual urine volume decreased from 182 mL to 50 mL and the I-PSS from 17.9 (± 4. 4. transrectal HIFU should not be considered for severely obstructed patients or those with an absolute indication for surgery. As a consequence. Similarly. In the initial US series. Ebert et al. detrusor pressure at Qmax and linear passive urethral resistance relation was observed.7 Durability The long-term outcome of 80 patients with a follow-up of up to 4 years and a minimum follow-up of 2 years 48 UPDATE MARCH 2004 .5-4.1. This technique is known as high-intensity focused ultrasound (HIFU).0 cm) is dependent upon the crystal used. an international Phase II clinical trial was initiated to evaluate the safety and efficacy of transrectal HIFU therapy for patients with LUTS due to BPH.5 (± 4.2 mL/s after 3 months.5.000 W/cm2.3 Morbidity/complications In general. incontinence or the need for blood transfusion have been reported in the literature. 4.therapeutic effect is the induction of heat. an ellipsoidal tissue volume approximately 2 mm in diameter and 10 mm in length is destroyed (1-3). Several other sites have confirmed these data (9-11). a statistically significant decrease in maximum detrusor pressure.4 (± 5. Pre-operatively. however. The focal length (2.5.0 MHz transrectal transducer for imaging and therapy. yet 37% were still obstructed according to the Abrams-Griffith nomogram. eight of whom had urinary retention.8 (± 2. The Qmax increased from 7. The site intensity can be varied from 1. 4.6). After therapy.200 W/cm2. half of the patients were in the equivocal zone and 13% were clearly unobstructed. and patients frequently discharge two to three drops of blood prior to micturition for several weeks. The authors concluded that the capability of transrectal HIFU to reduce bladder outlet obstruction was moderate (12). It was caused by inadvertent overfilling to 500 mL and subsequent rupture of the condom that covered the ultrasound probe. As a consequence. n = 20). n = 33) and 13.5) at 12 months (5). who studied in detail the early post-operative morbidity of several less invasive procedures. lasting for 3-6 days. This was most likely caused by using an inappropriately high-site intensity exceeding 2. the maximum site intensity was set at 2.6 mL/s to 15. Urinary tract infection occurs in around 7% of patients. Theoretically the prostate can be ablated by HIFU via a transabdominal or transrectal route. Haematospermia lasting for a maximum of 4-6 weeks is seen in the majority of sexually active patients.300 W/cm2. a multiplicity of laterally or axially displaced individual lesions is generated by physical movement of the sound-head. The Qmax increased from 8. 4.4 Outcome In June 1992. The histological effect of transrectal HIFU therapy using the Sonablate® on the canine and human prostate has been studied in detail (1-3.5 Urodynamics The urodynamic effect of transrectal HIFU therapy has been studied by Madersbacher et al. After HIFU. (7) reported on experience with 15 patients and a follow-up of 90 days.7) at 6 months and to 10.5.0 mL/s and the post-void residual urine volume decreased from 154 mL to 123 mL (7).6 Quality of life and sexual function There are no reliable data on quality of life after transrectal HIFU except from a study by Schatzl et al. 80% of patients were obstructed and a further 20% were in the intermediate zone according to the Abrams-Griffith nomogram. This complication led to reconstruction of the filling apparatus and the probe such that the problem can now be reliably avoided. The source for HIFU is a piezoceramic transducer. the Sonablate® (1-4). Clinical data are only available for one device. which has the property of changing its thickness in response to an applied voltage (1-3). several hundred patients have been treated with the Sonablate® at various sites. Within the same time period.
fcgi?cmd=Retrieve&db=PubMed&list_uids=8587227& dopt=Abstract Mulligan ED. Marberger M.nlm. http://www. Marberger M.55:3346-3351. UPDATE MARCH 2004 49 .ncbi. Susani M.8:17-26. Marberger M.ncbi. Saddeler D.44:146-149. Marberger M. Effect of high-intensity focused ultrasound on human prostate cancer in vivo. Lynch TH. controlled trials. http://www. 4. Curr Opinion Urol 1996. 2. High-intensity focused ultrasound in the treatment of benign prostatic hyperplasia.3 months (range: 13-48 months). which did not reach statistical significance.fcgi?cmd=Retrieve&db=PubMed&list_uids=7542168& dopt=Abstract Bihrle R. Smith JM. Madersbacher S.5. Application of Newer Forms of Therapeutic Energy in Urology. Madersbacher S. Therapeutic applications of ultrasound in urology. Marberger M. J Urol 1994. Br J Urol 1997. Improvement of urinary symptoms is in the range 50-60% and Qmax increases by a mean of 40-50%. Ackermann R.com/ Madersbacher S. http://www. Long-term efficacy is limited. Madersbacher S. however. http://www. 4. Djavan B. was noted for individuals with a higher Qmax and lower post-void residual urine volume.nlm.nih. 8.03) (14). Madersbacher S.8%) underwent TURP due to an insufficient therapeutic response during the 4-year study period. Kratzik C.fcgi?cmd=Retrieve&db=PubMed&list_uids=9052466& dopt=Abstract 3. In: Marberger M ed. Schmitz-Drager B.isismedical. http://www. Miller S.ncbi. 1995. Mulvin D. The retreatment-free period was significantly longer for patients with a pre-treatment average flow rate of more than 5 mL/s (p = 0. 5.gov/entrez/query. yet a few selection criteria have been identified. Pedevilla M.fcgi?cmd=Retrieve&db=PubMed&list_uids=7512658& dopt=Abstract Ebert T. Sanghvi NT. Curr Opinion Urol 1995.6:28-32.nih. Hood JP. Vingers L. Cancer Res 1995. Patients with one or more of the following criteria are unsuitable for transrectal HIFU therapy: • Prostates with dense calcifications (possibility of tissue cavitation) • Large prostates (> 75 mL) • Rectum to bladder neck distance over 40 mm • Large middle lobes • Higher grades of bladder outlet obstruction (BOO) . A similar trend. Foster RS. pp. Susani M.8 Patient selection The fact that only a handful of clinical studies with a limited number of patients have been published. Minimally invasive therapy in BPH. J Urol 1994. 115-136. Oxford: Isis Medical Media. The mean follow-up of the study population (excluding patients who crossed over to TURP due to insufficient therapeutic response) was 41. Marberger M.fcgi?cmd=Retrieve&db=PubMed&list_uids=7525992& dopt=Abstract Madersbacher S.gov/entrez/query.5. No data are yet available from randomized.(higher treatment failure rate) • Absolute indication for surgery.79:177-180. Tissue ablation in benign prostatic hyperplasia with high intensity focused ultrasound.5.has been studied (14).5:147-149. Fitzpatrick JM. High-intensity focused ultrasound (HIFU) in the treatment of benign prostatic hyperplasia (BPH). Curr Opinion Urol 1998.nlm.gov/entrez/query.ncbi. High-intensity focused ultrasound for prostatic tissue ablation. hinders a reliable statement concerning patient selection.nlm.nih. High intensity focused ultrasound for the treatment of benign prostatic hyperplasia: early United States clinical experience. Keio J Med 1995. 7.gov/entrez/query. 9. Applications of high energy focused ultrasound in urology. 4.nih.152:1956-1960. 6.nih. with a treatment failure rate of approximately 10% per year.05) and lower grades of urodynamically documented bladder outlet obstruction (p = 0.151:1271-1275. http://www. general anaesthesia or at least heavy intravenous sedation is required.gov/entrez/query. Thirty-five men (43. Greene D.ncbi. Graefen M. 4. Donohue JP.10 REFERENCES 1.9 CONCLUSIONS Transrectal HIFU therapy is the only technique that provides non-invasive tissue ablation.nlm.
37:687-694.gov/entrez/query. Adverse events.6.ncbi.6.6.3-41. although intravenous sedation is required in some patients (1).5 Randomized clinical trials TUNA® has been compared with TURP in one trial (8) with 12-month follow-up data. Gleave ME.nih. Eur Urol 1996.fcgi?cmd=Retrieve&db=PubMed&list_uids=9181450& dopt=Abstract Sullivan LD.fcgi?cmd=Retrieve&db=PubMed&list_uids=8977064& dopt=Abstract Schatzl G. Madersbacher S. 4. Marberger M. Post-operative urinary retention is seen in 13. J Urol 1997.nlm. Marich KW. http://www. Saito S. Goldenberg LG. http://www. Schmidbauer CP.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186334& dopt=Abstract Madersbacher S.nlm.158:105-111. Tachibana M. 90-95% of patients are catheter-free (1). 4. These data are statistically significantly better than at baseline and surpass the expected placebo effect. J Endourol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=9052465& dopt=Abstract Madersbacher S.nih. There is no convincing evidence that prostate size is significantly reduced following TUNA® (7-9). Schatzl G. 12. Improvements in Qmax vary widely from 26-121% in non-retention patients. http://www. The urodynamic impact of transrectal high intensity focused ultrasound on bladder outflow obstruction. Nakamura K.2% required additional treatment (8). dysuria.nlm.gov/entrez/query. Klingler CH.11:197-201.nlm. Djavan B.3 Morbidity/complications Is usually performed as an out-patient procedure under local anaesthesia.6. were more frequent in the TURP arm. such as bleeding. Irritative voiding symptoms lasting up to 4-6 weeks are frequently present (2).2 Procedure The TUNA® device delivers low-level.6. Stulnig T.6% of patients and lasts for a mean of 1-3 days. Long-term outcome of transrectal high intensity focused ultrasound therapy for benign prostatic hyperplasia.gov/entrez/query.1 Assessment No specific diagnostic work-up prior to TUNA® is necessary. erectile dysfunction.nih.10. a statistically significant decrease in maximum detrusor pressure or detrusor pressure at Qmax was demonstrable. In both treatment arms. Eur Urol 2000.6 TUNA® 4. 4.4 Outcome Several non-randomized clinical trials have documented the clinical efficacy of this procedure with a fairly consistent outcome (3-7). Lang T. The early postoperative morbidity of transurethral resection of the prostate and of four minimally invasive treatment alternatives. Marberger M. High-intensity focused ultrasound energy for benign prostatic hyperplasia: clinical response at 6 months to treatment using Sonablate 200™. In all studies. within 1 week. 50 UPDATE MARCH 2004 . The symptomatic improvement reported ranged from 40-70%. although improvements were slightly higher in the TURP arm. http://www. http://www.ncbi. Murai M.gov/entrez/query.nlm. 11. Continence status is not affected. A recent report with 5 years follow up in 188 patients demonstrated a symptomatic improvement of 58% and an improvement in flow rate of 41%. 14. Marberger M.gov/entrez/query. yet a number of patients remained in the obstructed range after TUNA® therapy.fcgi?cmd=Retrieve&db=PubMed&list_uids=10828669& dopt=Abstract 4.nih. 21.ncbi. Schatzl G.6. urinary tract infection or strictures. Early experience with highintensity focused ultrasound for the treatment of benign prostatic hyperplasia. Improvement in Qmax was significantly higher after TURP than after TUNA®. 4. Br J Urol 1997. McLoughlin MG. 4. 13. there was a significant decrease in AUA symptom score and bother score.79:172-176.ncbi.6 Impact on bladder outflow obstruction The impact of TUNA® on bladder outflow obstruction as assessed by pressure-flow studies was determined in seven clinical studies (7-13). Baba S.nih.30:437-445.ncbi. radio-frequency energy to the prostate via needles inserted transurethrally (1).
fcgi?cmd=Retrieve&db=PubMed&list_uids=9352697& dopt=Abstract 2. Wiklund P.gov/entrez/query.7 Durability Several authors have reported on the long-term efficacy of the TUNA® procedure.80:579-586.nlm. J Urol 1998. Within 1 year.158:105-110. Shumaker BP. TUNA® is not suitable for patients with prostate volumes exceeding 75 mL or isolated bladder neck obstruction. Narayan P.nlm.nih.ncbi. http://www. 4.nlm.gov/entrez/query. Perez-Marrero R. Schulman et al.6.nih. Marberger M. Shumaker BP. Giammarco L.fcgi?cmd=Retrieve&db=PubMed&list_uids=9240192& dopt=Abstract Roehrborn CG.fcgi?cmd=Retrieve&db=PubMed&list_uids=11223750& dopt=Abstract Bruskewitz R. http://www.gov/entrez/query.nlm. Long-term evaluation of transurethral needle ablation of the prostate (TUNA) for treatment of symptomatic benign prostatic hyperplasia: clinical outcome up to five years from three centers.10 REFERENCES 1. Pillai M. http://www.nih. Transurethral needle ablation for benign prostatic hyperplasia: 12-month results of a prospective.nih.ncbi. Eur Urol. http://www. Madersbacher S. 2003. J Urol 1997. 8 9. Hastie KJ. Goldwasser B. 3.35:119-128.ncbi. Eardley I.fcgi?cmd=Retrieve&db=PubMed&list_uids=9933805& dopt=Abstract Schatzl G. Garafolo F. Chapple CR. positive results can be translated into percentages ranging from 5-42% (1). It results in an improvement of urinary symptoms in the range 50-60% and Qmax increases by a mean of 50-70%.66:89-93.nlm. Transurethral needle ablation (TUNA). Perez-Marrero R. Schulman CC. Lang T. 4. Fitzpatrick JM.nih. Pressure-flow studies in men with benign prostatic hypertrophy before and after treatment with transurethral needle ablation. Galosi AB. Br J Urol 1997. Maehlum O. Lynch TH. multicenter US study. Issa MM.9 CONCLUSIONS TUNA® is a simple and safe technique and can be performed under local anaesthesia in a significant number of patients. Oesterling JE. Ostrem T. Naslund MJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=9510346& dopt=Abstract Schulman CC. UPDATE MARCH 2004 51 .ncbi. Frick J.ncbi.6. Improvement in Qmax exceeding 50% was seen in 53% of patients after 36 months. Jungwirth A. (14) recently presented 3-year follow-up data on 49 patients after TUNA®.ncbi.ncbi. Muzzonigro G.157:98-102.gov/entrez/query.nih.gov/entrez/query.gov/entrez/query. Potts KL. Cutinha PE. http://www. 4. Transurethral needle ablation (TUNA) of the prostate: clinical experience with two years’ follow-up in patients with benign prostatic hyperplasia (BPH). Issa MM. Woo H. Clinical efficacy has been proven in only one randomized controlled trial. Roehrborn CG.nlm. Bruskewitz RC.159:1588-1593. Chapple CR.51:415-421. Urology 1998.44:89-93.gov/entrez/query. http://www. Urol Int 2001.fcgi?cmd=Retrieve&db=PubMed&list_uids=9554360& dopt=Abstract Zlotta AR. 5. Woo H.6. Yehia M.ncbi.nih.80:128-134. Cristalli AF.4. Safety and efficacy of transurethral needle ablation of the prostate for symptomatic outlet obstruction. Naslund MJ. 6. A prospective randomized 1-year clinical trial comparing transurethral needle ablation to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia.nlm.8 Patient selection Few selection criteria have been identified. Ekman P. http://www. 7. Oesterling JE.nlm. Issa MM. Eur Urol 1999.nih. Long-term follow-up data exceeding this time period are not yet available. J Urol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=12814680& dopt=Abstract Rosario DJ. Giannakopoulos X. A critical review of radiofrequency thermal therapy in the management of benign prostatic hyperplasia. and there is limited evidence of long-term efficacy. Br J Urol 1997. Ten patients (20%) underwent TURP because of an insufficient therapeutic response (1). http://www. Zlotta AR.gov/entrez/query. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=9186334& dopt=Abstract Ramon J. The early postoperative morbidity of transurethral resection of the prostate and of four minimally invasive treatment alternatives. Minardi D.6. Transurethral needle ablation of the prostate for the treatment of benign prostatic hyperplasia: a collaborative multicentre study.
fcgi?cmd=Retrieve&db=PubMed&list_uids=8683692& dopt=Abstract Millard RJ.0. 14. J Urol 1996. ProstaLund® (Lund Systems. 4. Issa MM. France). urinary retention is usual in patients treated with high-energy TUMT.gov/entrez/query.nih. the average catheterization time is 2 weeks. High-energy treatment is also well-tolerated. http://www. For patients treated with low-energy protocols. The majority of data in the literature on thermotherapy has been based on the Prostatron® device. 12.ncbi. Most patients experience perineal discomfort and urinary urgency for several days after treatment. The main difference between the devices available is the design of the urethral applicator. and Targis® (Urologix. 13.156:413-419. but subsequently higher energy levels were used to improve treatment outcomes and response rates. On a conceptional basis. Occasionally.8-5%) (7. The similarity in catheter construction consists of the presence of a microwave antenna positioned in the tip of the catheter just below the balloon. J Urol 1997.nih. Tamaddon K. Transurethral needle ablation of the prostate: report of initial United States experience. Neurourol Urodyn 1996. No tissue sloughing occurs and urinary retention is expected in up to 25% of patients (2-6).4 Morbidity Morbidity following TUMT is an important issue.158:1834-1838.nlm.1 Assessment Diagnostic endoscopy is essential because it is important to identify the presence of an isolated enlarged middle lobe or an insufficient length of the prostatic urethra.nlm. Eur Urol 1998. haematuria is noticed. 11. 4.10.nih.15:619-628.49:847-850. A study of the efficacy and safety of transurethral needle ablation (TUNA®) treatment for benign prostatic hyperplasia. http://www.ncbi. the characteristics of the applicators differ.2). http://www. although pain medication needs to be administered to most patients prior to or during therapy. Outcome: objective.7.7. Bergamaschi F.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9187689& dopt=Abstract Steele GS.8).nih.ncbi. Ordesi G. In contrast to the low-energy protocol. Only two papers mention erectile dysfunction following thermotherapy (incidence 0.ncbi. To date.gov/entrez/query. Transurethral needle ablation (TUNA™) of the prostate: clinical experience with three years follow-up in patients with benign prostatic hyperplasia (BPH). 4.nlm. Zlotta AR.2 Procedure TUMT is a registered trademark of Technomed Medical Systems (France). 33(Suppl 1):148. the retrograde ejaculation rate ranges from 0-11%. Corrada P. Harewood LM.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334612& dopt=Abstract Schulman CC. they are all similar in delivering microwave energy to the prostate with some type of feedback system. Sleep DJ. but not usually for longer. 4. Urology 1997. and remarkably 52 UPDATE MARCH 2004 . Sweden).fcgi?cmd=Retrieve&db=PubMed&list_uids=8916114& dopt=Abstract Campo B.7. tens of thousands of patients worldwide have been treated with the Prostatron® device. Initial experience focused on low-energy protocols. subjective and urodynamics Low-energy protocols: The standard operating software for the Prostatron® is version 2. Transurethral needle ablation of the prostate: a urodynamic based study with 2-year follow-up. USA).gov/entrez/query. Also incorporated in the catheter are one or more temperature sensors that differ in the way in which they measure temperature. Transurethral needle ablation (TUNA) of the prostate: a clinical and urodynamic evaluation. a company considered to be the pioneer of microwave thermotherapy. Other thermotherapy devices have also been developed: Prostcare® (Brucker. a catheter may be necessary for an average of 7 days. while for high-energy protocols. this figure increases up to 44%. Apart from differences in the construction of the catheter. A treatment catheter is connected to the module and inserted into the prostatic urethra.3 The microwave thermotherapy principle Microwave thermotherapy devices consist of a treatment module that contains the microwave generator with a temperature measurement system and a cooling system. In these cases. Low-energy TUMT is well-tolerated by patients. significantly affecting the heating profile (1. http://www. Fluid channels surrounding the catheter provide urethral cooling.7 TUMT 4.7.gov/entrez/query.
the principle of stepwise energy increments was abandoned and the treatment was initiated at an 80 W energy level. with a decrease in Madsen symptom score from around 13 to 4. When applying higher energy levels.17). Both groups had showed significant relief of bladder outlet symptoms. the so-called Prostasoft® 3.5. (29) reported a 5-year retreatment rate in 45 patients of 84. the total treatment duration is shortened to only 30 minutes. High-energy protocol: The first reports on the application of high-energy levels using Prostasoft® 2.4. 64%). More recently. (3). 4.9-13). Third.6 mL/s at baseline to 14. the cooling temperature starts at a lower value (8oC) and is also linked to rectal temperature.4% with medication (46. a decrease in IPSS from 18.6 Prostatic temperature feedback treatment A treatment protocol with calculated tissue necrosis based on simultaneous intraprostatic tissue temperature has been introduced with the Prostalund Micowave apparatus (PLFT. On a conceptual basis. Energy delivery is now guided by the rectal temperature sensor via a feedback loop. (18) and Devonec et al. On the other hand. 47%). increase in flow rate (74% vs. (30) found a retreatment rate after 5 years in 71 patients of 68%. there was a significant improvement in all clinical parameters. This Prostasoft® 3.14. representing a mean improvement of approximately 35% over baseline. The clinical efficacy of TUMT has been confirmed in several randomized.7 Durability Several studies using low-energy thermotherapy report on surgical retreatment rates for up to 1 year of 11% (25) and 10% (20). This study showed significant improvement after both TUMT and TURP in symptom score. It was concluded from clinical experience that a shorter duration of treatment did not alter efficacy or decrease morbidity (22). 4. It was concluded that satisfactory results were obtained after both treatments.7%) or endoscopic surgery ( 37. After TURP and thermotherapy. The best candidates for this treatment protocol appeared to be patients with moderate-to-severe bladder outlet obstruction.9 and an increase in maximum flow rate from 8. (11) reported only low retreatment rates with significant subjective and objective improvements. changes to the Prostasoft® software have recently been reported. In this study. (19) and demonstrated clinically significant improvements. Pace et al. respectively.7. These improvements are noted from 6 weeks and persist over a period of 5 years (16. (24) found in 56 patients.2 to 7. Changes in objective parameters are less pronounced.1 mL/s at 26 weeks of follow-up. Secondly.1.1 mL/s to 188.8.131.52%). Qmax improved from 9.similar clinical results have been reported worldwide from several centres (2-4. but one patient in each group required another treatment. (26) found in 167 patients.18) additional TURP was performed in only three out of UPDATE MARCH 2004 53 . with improvements in free flow being 100% and 69%. at 12 months. No serious complications occurred in either group. Finally.7. while Daehlin et al.5 protocol can therefore be considered to be high-intensity-dose TUMT. an increase in maximum flow from 9. These objective and subjective improvements were sustained at 52 weeks. multicentre study against TURP. quality of life (IPSS) (69% vs. Qmax. the urethral temperature feedback system was also abandoned.6 at baseline to 5.5 High-intensity-dose protocol Although the results following high-energy TUMT are good. and those with larger prostates (22).5 at 26 weeks. ProstaLund Feedback Treatment) (27). The mean increase in Qmax is 3-4 mL/s. as measured by pressure-flow studies.9 to 16. In a study by de la Rosette et al. Symptomatic improvement is significant. 94%) or decrease in detrusor pressure at max. a decrease in IPSS from 19.8 mL/s and cavities within the prostatic tissue of 54 of the 56 patients (95%). at six months.5 were published by de la Rosette et al. there was no statistically significant differences between the 2 treatments in decrease in symptom score (66% vs 65%). Van Cauwelaert et al. Recently Tsai et al. Only decrease in prostate volume was higher in the TURP group (51%) than in the PLFT group (30%) (28). randomized. At 1 year of follow-up. 4.15). There appeared to be a good correlation between the presence of a cavity and uroflowmetry improvement (21). De La Rosette et al. flow rate (34% vs. the outcome seems improved and may eventually result in a more durable response. SHAM-(placebo) controlled studies (4. At 3-months of follow-up TRUS identified a prostatic cavity in almost 40% of patients. A randomized study comparing TUMT with TURP was performed by Dahlstrand et al. (5.1 to 5. Firstly. In a prospective. Although the decrease in symptom score was more pronounced after TURP (92%) than after TUMT (78%). with improvements observed following high-energy TUMT being in the same range as those seen after TURP. international. post-void residual urine volume and grade of bladder outlet obstruction. the symptomatic improvement was 78% in the TURP group versus 68% in the TUMT group. One-year follow-up results of a prospective randomized study comparing high-energy TUMT with TURP were reported recently (23). the mean Madsen score improved from 13.5 protocol differed significantly from former protocols. the European BPH Study Group performed a multicentre study of 116 patients using high-energy TUMT (20).
with sustained and durable long-term results. 1992.9 • • • CONCLUSIONS High-energy TUMT produces significant subjective and objective improvement.116 patients.nlm.nlm.gov/entrez/query.nih. Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: results of the United States Prostatron Cooperative Study. Claro JD. Scand J Nephrol 1994.ncbi. 4. 7.fcgi?cmd=Retrieve&db=PubMed&list_uids=7518982& dopt=Abstract Servadio C. 3. pp. Quality of life assessment in patients treated with lower energy thermotherapy (Prostasoft 2. http://www.nih. In a larger study of 200 patients. Hallin A.7.nlm. Debruyne FM. Alivizatos G. Br J Urol 1996.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8535682& dopt=Abstract Ogden CW. Lancet 1993.28:83-89. Due J.7. with a success rate of 72% after 6 months in 29 patients (32).nlm. 175-186. with a follow up of 2 years in 155 patients.ncbi.8:217–219.nlm. Johnson H. 8.gov/entrez/query.ncbi.7.fcgi?cmd=Retrieve&db=PubMed&list_uids=7524916& dopt=Abstract Francisca EA. The heat is on – but how? A comparison of TUMT devices. 4. Ejaculatory dysfunction after transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia.ncbi. Good results with regard to catheter release have been obtained. http://www.gov/entrez/query.nlm. Eliasson T. http://www. Mattiasson A. McKiel CF. J Urol 1993. De Wildt et al. Regan JB. J Endourol 1994. Reddy P. de Wildt MJ. 4. Debruyne FM. Rodrigues Netto N.8 Patient selection As the morbidity is relatively low and the treatment can be performed without anaesthesia. Deirsson G.ncbi. Sham versus transurethral microwave thermotherapy in patients with symptoms of benign prostatic bladder outflow obstruction. Tomera KM. Cortado PL. only 7% failed to respond (33). http://www. Urology 1994.nih. such patients with retention can benefit from this treatment. Morbidity after TUMT consists mainly of the need for catheter drainage after treatment due to urinary retention. Ten years of clinical experience in transurethral hyperthermia to the prostate.76:614-618. 54 UPDATE MARCH 2004 . patients in poor health are particularly good candidates for thermotherapy. Wagrell L. http://www.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=7678047& dopt=Abstract De la Rosette JJM. Ramsay JW.158:1839-1844.0): results of a randomized transurethral microwave thermotherapy versus sham study. Non surgical treatment of BPH.fcgi?cmd=Retrieve&db=PubMed&list_uids=9334613& dopt=Abstract Marteinsson VT. 5. In: Fitzpatrick JM ed.gov/entrez/query. 6. Walden M.fcgi?cmd=Retrieve&db=PubMed&list_uids=7692092& dopt=Abstract Dahlstrand C. but with increased morbidity.fcgi?cmd=Retrieve&db=PubMed&list_uids=8944513& dopt=Abstract Blute ML. Pettersson S. documenting five surgical interventions at 1-year follow-up in 85 patients treated.gov/entrez/query. Bolmsjo M.10 REFERENCES 1.nih. Transurethral microwave thermotherapy (TUMT) in benign prostatic hyperplasia: placebo versus TUMT.44:58-63.nih. J Urol 1997. (31) confirmed these findings. Carter SS. http://www.341:14-17.nih. Transurethral microwave thermotherapy for uncomplicated benign prostatic hyperplasia.gov/entrez/query. High-energy TUMT is associated with improved objective results compared with low-energy TUMT. Lynch JH. http://www.nlm.ncbi.nlm.ncbi. Kiemeney LA. Br J Urol 1995.nih. Transurethral microwave thermotherapy versus transurethral resection for symptomatic benign prostatic obstruction: a prospective randomized study with a 2-year follow-up. Hendriks JC. de la Rosette JJ. http://www. Froeling FM. 4. In particular.gov/entrez/query.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7516577& dopt=Abstract 2. 9. Sankey NE. d’Ancona FC.78:564-572. SIU report 3. Erlandsson BE.150:1591-1596. Edinburgh: Churchill-Livingstone. Hellerstein DK.
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alpha-blocker therapy may be continued. which will depend on the type of treatment modality undertaken. The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume. TUIP. FOLLOW-UP All patients who receive treatment require follow-up. 5 ARI’s are an acceptable treatment option for patients with bothersome LUTS and an enlarged prostate (> 40 mL) and can be used when there is no absolute indication for surgical treatment. It is not recommended as a first-line surgical treatment for patients with LUTS. TUMT is an acceptable alternative to TURP and for those who prefer to avoid surgery or who no longer respond favourably to medication. UPDATE MARCH 2004 57 . 5. Transrectal HIFU therapy is currently not recommended as a therapeutic option for elderly men with LUTS and is considered an investigational therapy. 5. but may have a role in the treatment of high-risk patient subgroups. 4. 5. disappointing long-term data and higher costs have resulted in a substantial decline in the clinical use of lasers. Surgical management (TURP. provided there is no deterioration of symptoms or development of absolute indications for surgical treatment.4. 5.3 5-alpha-reductase inhibitors Patients should be reviewed after 12 weeks and at 6 months to determine their response. 7. 5. patients may be seen within 6 weeks to discuss the histological findings and to identify early post-operative morbidity. 9. 2. If patients gain symptomatic relief in the absence of troublesome side-effects. The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume. TUNA® is an encouraging technology as an alternative with acceptable results. Patients who fail treatment should have urodynamic studies with pressure-flow analysis. Subsequent review is as for alpha-blocker therapy. Assessment includes: • I-PSS: recommended • Uro-flowmetry and post-void residual urine volume: recommended • Urine culture: optional • Histology: mandatory. The following are recommended: • I-PSS • Uro-flowmetry and post-void residual urine volume.8 1. Long-term follow-up should be scheduled at 3 months to determine the final outcome. Patients should be reviewed at 6 months and then annually. Alpha-blocker therapy is a treatment option for patients with bothersome LUTS who do not have an absolute indication for surgical treatment.2 Alpha-blocker therapy Patients should be reviewed after the first 6 weeks of therapy in order to determine their response.4 Surgical management Following surgical treatment. 6.1 Watchful waiting Patients who elect to pursue a WW policy should be reviewed at 6 months and then annually. Significant post-operative morbidity. These patients may be candidates for urodynamic assessment and surgical treatment. HoLRP is a promising new technique with outcomes in the same range as those of TURP. 8. open prostatectomy) is recommended as first-line treatment for patients with complications due to BPH with (an absolute indication for treatment of) LUTS. provided there is no deterioration of symptoms or development of absolute indications for surgical treatment. 5. Patients who subsequently develop chronic retention will require evaluation of their upper tract by serum creatinine measurement and/or renal ultrasound. 3. RECOMMENDATIONS FOR TREATMENT The WW policy should be recommended to patients with mild symptoms that have minimal or no impact on their quality of life.
58 UPDATE MARCH 2004 . at 3 months. The following time schedule is appropriate for the majority of minimally invasive therapies: within 6 weeks. and then annually.5 Alternative therapies Long-term follow-up is recommended because of concerns about the efficacy and durability of alternative therapies.5. Assessment includes: • I-PSS: recommended • Uroflowmetry and post-void residual urine volume: recommended • Urine culture: optional • Histology where available: mandatory. at 6 months. The intervals for follow-up will depend on the treatment modality employed.
ABBREVIATIONS USED IN THE TEXT This list is not comprehensive for the most common abbreviations. Colorectal and Ovarian Cancer Screening Trial predictive positive value Prostate weight. Quality of life. Symptoms.6. Agency for Health Care Policy and Research European multicenter double-blind study to assess the efficacy and safety of Alfuzosin (5 mg twice daily) versus finasteride (5mg once daily) and the combination of both in patients with symptomatic BPH alpha reductase inhibitor American Urological Association Acute urinary retention BPH Impact Index bladder outlet obstruction benign prostatic enlargement benign prostatic hyperplasia blood urea/nitrogen computed tomography Danish Prostate Symptom Score velocity of detrusor contraction at 40 mL volume dihydrotestosterone digital rectal examination European Prostate Cancer Detection Study European Randomized Study of Screening for Prostate Cancer high-energy thermotherapy high-intensity focused ultrasound Holmium laser resection of the prostate International Continence Society International Prostate Symptom Score interstitial laser coagulation intravenous pyelography intravenous urography low-osmolar contrast material Linear Passive Urethral Resistance Relation lower urinary tract symptoms magnetic resonance imaging presumed circle area ratio Proscar Long-term efficacy and safety study Prostate. Maximum flow rate prostate-specific antigen post-void residual volume average flow maximum flow mean flow for middle 90% of voided volume randomized controlled trial Receiver Operating Characteristics Quality of Life visual laser ablation time from Qmax until 95% of volume voided transrectal ultrasonography transurethral incision of the prostate transurethral microwave therapy transurethral needle ablation transurethral resection of the prostate transurethral electrovaporization Urethral Resistance Index visual laser ablation watchful waiting (deferred treatment) AHCPR ALFIN study ARI AUA AUR BII BOO BPE BPH BUN CT DAN-PSS dL/dt 40 DHT DRE EPCDS ERSPC HE-TUMT HIFU HoLRP ICS I-PSS ILC IVP IVU LOCM LinPURR LUTS MRI PCAR PLESS PLCO PPV PQSF PSA PVR Qav Qmax Qm90 RCT ROC QoL VLAP Tdesc TRUS TUIP TUMT TUNA® TURP TUVP URA VLAP WW UPDATE MARCH 2004 59 . Lung.
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